A TEXT-BOOK
OF X-RAY DIAGNOSIS
by BRITISH AUTHORS
" W hat shadows we ore, and what shadows we pursue.”
Edsiuvb BruKE, Sept 9th, 17S0
A TEXT-BOOK
OF
X-RAY DIAGNOSIS
BV BRITISH AUTHORS
IN THREE VOLUMES
Edited by
S. COCHRANE SHANKS, M.D., F.R.C.P., F.F.R.
EOXOUST DISECTOB, X EAT IlIiO^OSTIC bCTARTEEXT, C^TERSITT COU.EGE ROSFlXil.
PETER KERLEY, M.D.. F.R.C.P., D.M.R.E.
MTSicus TO iHt X brriXTMX-^T, wtaransTta HosmAi ,
fillOtOClST, »or*l. CBESt HWfTil, ETC.
AND
E. W. TWINING, M.R.C.S., M.R.C.P., D.M.R.E.
aiZ>:oioo)<r, aoni rrriBjfjBT, juxchb.«te« , »4i>joiccj«t, fowsTTf fmmtai
liTB BCXTESliX rFOFe«SOB. t«)T*t COtttQS OT SCRCtOT*
iicrntp JT BinotocT rwEn^rtr or kAXCRSTEit etc
VOLUME 11
With 307 illustrations
LONDON
H. K. LEWIS & Co. Ltd
1938
ttri4 tff It
rtprtnird
Peprinfrit
Mureh I03«t
January 1913
Fthrutiry I'Ul
I book I
iPKXWCnON
>K\REOONCWV
STANDARD
Tit Typtiffrafil yand Ifiiidmi
of Ovi UtoL eanfjrm to the
nvOorwd trxmtmj nUndirfl
PIBLISHERS ^OTE
1 Ml -ji/e of tlic \oUiine*. in thu rcpnnt lias l)«?n rediicetl in order
10 <iinipl\ tlie ngulitions now m forc-o prescribing tlio area
of tiic t^pc hurfice in reUtion to the size of the page
The t\^x am is tlie same m the first i«sue and tlie reduction
in M7e li IS t ikon place at the expense of tlie nnrgin
riie Pnblidiers regret this reduction one which bomewlnt
mars the apjiearnnce of the \olumcs and tlie\ liope that it will be
a(«pto<l ns A wartime necessitt \Mien a new etbtion of the
work IS called for it wnll Ik* omUAtnnr tn return to the
ongmal format
LIST OP CONTRIBUTORS
S L Baker, P hD, jr Sc, MRCS.LRCP.BPH,
Procter Professor of Patliology and Pathological Anatomy,
Umrersit} of Manchester.
Hugh Cairns MA,MB,BS,PRCS,
Nuffield Profe'«‘?or of Surgery, University of Oxford, Surgeon,
Neuro-Siirgicdl Department, London Hospital , late Surgeon,
National Hospital, Queen Square , late Surgeon, Hospital for
Paralysis and Epilepsy, Maula Vale , late Hunternn Professor,
Royal College of Surgeons
F CurPBCUZi Golding, MB, Ch M , M R C P , D 31 R E ,
Assistant Radiologist, AtuMIcsev Hospital and British Red Cross
Clinic for Rheumatism , Honorary Radiologist, Royal National
Orthopedic Hospital
E Ddit Gran, M A , M D , F F R , D M R E .
Honorary Radiologist, Ancoat? Hospital, Manchester , Visiting
Radiologist, Path Hospital, Davylmlme
H K GBAimr Hodosov, 0 ro 31 B . BS , F R CP , FF R , DM R E ,
Honorarj Phjsiciaii m charge Department of X*rai Diagnosis,
Jliddlesex Hospital Honorary Radiologist, Central London
Throat, Nose and Ear Hospita’
Donald HotvTEH, M D , FRCP,
Pliysieian, with chaige of Out patients, London Hospital
31 H Jute, BA, 3IRCS, LRCP, FPR, D31RE,
Radiologist, London Hospital
ppTLR IvFRLuy, 31 D, FRCP, FFR, D3IRE,
Physician to the X ray Department, Westminster Hospital ,
Radiologist, Royal Chest Hospital
0 Jlnmnos 31 snsiT vll, 3ID, 3IS, PROS,
Surgeon, Channg Cro«s Hospital , Surgeon, Victoria Hospital
for Children, Examiner m Surgeiy, Universities of London
ami 3Ianche8tcr
Russell J Reynolds, CBi7,3IB,BS,FRCP, P.F R , D 31 R E ,
PhjBician in charge Departments of Radiologj’ and Electro*
therapy, Charmg Cross Hospital , Honorary Radiologist,
National Hospital, Queen Square , late Hunterian Professor,
Rojal College of Snigeons
LIST OF CONTRIBUTORS
T1
R E ItoBFRT'i R'>c AID Di'H FFIl,DA[RE
Hononrj Radiologist, Liverpool Rojal Infirmar} Victona
Central lIo<?pital Lnerpool Matcmitj Hospital and Liverpool
Ridmm Institute Consulting Radiologist Lnerpool Heart
Hospital Lecturer in Radiologj and in Applied Anatomy
(Radiological) Unnersity of Liverpool
S C ociTRANE Shavks AID FRCP FFR,
Honorarj Director \ ray Diagnostic Department, Unnersity
College Hospital
CrCTL O Tcyu MB Ch B FFR
Honornra Radiologist General Hospital and Children s Hospital
llinnmgliam
J iAM, TiCRsta AIRCS LRCP DAIRE
\ssistant Radiologist (hanng Cross Hospital
I M MRCS MRCI» FFR DAIRE
Radiologist Ro\al InRmmn Alanchcster Radiologist Chnstie
Hospital late Hunterian Professor Rojal College of Surgeons
Lecturer in Hadtolog> Universitj of Manchester
> RolI\^ UruiAMs Ml) FRCP FFR DAIRE
\‘<»ntatit Director Radiological Department St Mary s
Hc'.pital Hononr> Radiologist, WilJesdcn Genervl Hos2>Jtal
I «>T OForoi Mii^on MC MB Ch M FRCS LRCP FRCOG
Olistctncaiid G^TiajcoIogical Surgeon I n erpool Ro> al Infiimara
Consulting Obstetncian Malton Hospital Lnerpool
H M MoriTii MRCS LRCP LDS IFR DM RE
Assistant Radiologist Cm s Hosjiital Padiologist C uj s
llospiid Dental School
PREFACE
Tiie objtct of the Editors m presenting this text book is to provide ^vlthm
reasonable bmtts a comprehensive survey of the present position of X ray
<liagnosi3 Diagnostic radiology is becoming an increasingly complex specialty,
and it IS difficnlt for one person to be equally expert m all its branches The
Editors are fortunate therefore m havmg the help of collaborators, both radio-
logical and clinical, -who are distinguished in particular branches of the subject
It IS hoped that this has made the uork the more authoritative and that it
wll be of value not only to the itost graduate student of radiology but also to
the clinician In conformity u ith this design only essential details of tech
nique are included, and the subject of X ray physics is not dealt with
For convemence of reference, the work is published in tliree volumes, each
containing as far as possible subjects of allied interest Thus Vol I deals
mainly mth the thorax, Vol H with the abdomen, and Vol HI with the
skeletal and nervous systems
It 13 not possible, even vathm the generous hmits alloued bj the publishers,
to illustrate every condition demonstrable by radiology, but the illustrations
chosen are, it is hoped, representative, and give due emphasis to the common
lesions met with in radiological practice Considerable interchange of material
for illustrations has taken place betneen the various contributors to tbc book,
ami the Editors are greatly indebted for the loan of illustrations from other
colleagues, detailed acknou lodgments of w hich will be found at the beginning
of each volume They are also grateful to Mr Boutall, of Messrs Vaus &.
Crampton, for the care and attention he has given to the preparation of the
blocks, and to Messrs HnzeU Watson A Viney for their careful work with
the pnnting
Finally, the Editors desire to express (heir sincere thanks to the publishers,
and m particular Mx H L Jackson and Mr F Boothbj, for their co operation
and advice, without u Inch this book could not have come into bemg
February 1938
SUVMARy OF CONTENTS
vot. I
CARDIOVASCULAR SYSTEM Pi,T£R Ktulfy, MD,
FRGP.FFR.DAtRfe
RESPIRVrORY SYSTEM E W Tnststno MRCS,
MRCP rPR.DMRE
URINARY AND MALE GENITAL TRACTS C Jt.'r^^^os
Marsh \LL "M D MS FRCS.andS Cochrane SIlv^Ks,
MD FRCP FPR
VOL n
ALIMENTARY TRACT S Coc^BA^B Sua>ks
BILIARY TRACI Peter Keri^ei
ABDOMEN S Cochrane SiiantvS
FEMALE GENITAL TRACTT R E Robert^ B Sc M D
DPH FFRjDMRE nn<l .1 St George IVilson
MC M B , Cli "M , F R C S , r R C 0 G
OBSTETRICS R E Robert^
voL> m
CENTRAL NERVOUS SYSTEM Hacn Cairns M A MB
B S F R C S and M H Jote BA MRCS LRCP
FFR DAI RE
ACCESSORY NASAL SINTJSES LABYRINTH AND
MASTOID PROCESSES H K Grailvm Hodgson
CIO AIB BS.FRCP FFR DM RE
TEETH AND JAIVS H AI M'ortk, AIRCS LRCP
L D S r r R , D M R E
BONES AND JOINTS AND ^OFT TISSUES S L B\kfr,
PhD 5ISc MRCS. LRCP DPH P Campblu,
Goldinc, mb ChAI. MRCP DAIRE, E Derr
GR4-i, MA MJ) FFR. DMRE , H K Graham
Hodgson Donald Hunter, AI D FRCP, 31 H
JUPE, PPTER KERLEA , R E ROBERTS., S CoCURiNE
S]i , Clcil G Teaxx^ M B , Ch B F F R , T Fane
Ttbrnei.SIRCS.LBGP.DAIRE , E M' Tavtntno,
E Rohan W iluams. jrD.rRCP.FrR.DAIRE
CINER \DIOGRArHY Russell J Rf\nolds, C C E 31 B ,
BS FRCP FFR, DAIRE
COMEiSTS or VOLUME TM'O
PAOE
List op CovTBiuirTOBS . v-vi
Preface , vu
SuMltARV OF COVTEVrS . ix
PAJiT ONE
ALIMENTARY TRACT
SEcnoh I
SALI;AR1 glands rHARY>X AXD (ESOPKAOUS
CH4PTPW
I The Sauvara Glajids 1
II Tub NoBJiAt, Pharynx and CEsopiiaous 8
ni Diseases of Tire Pharynx and (Esopiugcts 14
SEcnov n
STOIIACH DEODENTJM AND DlATnRAOM
IV General Teciimqde 34
V The Norsial Stomach 39
VI Gastric Ulcer 67
\’1I Other I^^LA^DlATORN Lesions of niB Stomach 80
VIII Neoplassis of xnE Stomach 8G
lA. Miscellaneous Gastric Conditions 103
X The Norsial Duodenmim 114
XI Duodenal Ulcep and Otiibb Inflamsiatory Lesions 124
XII Miscellaneous Duodenal Lesion-s 138
XIU The Stojiach and Duodenum after Operation 161
XIV The Diathraom . , .170
Section III
SMALL EfTESTINF APPENDIN AND LABOL INTESTINE
XV The Smvll Intestine Technique Anatomy, and
Physiology , . 107
XVI Diseases or the S3I\ll Intestinf 202
CONTF^TS
XU
ClIAltTJl
\MI Tut Virrsms
Will F\Axrr\\TiON oi the Colox
\I\ \nato«\ \nu Pii\«iolog\ ot niE Colon
\\ Vn iTOJUCXL \ ARIX■^0^^> OP THE COLON
\XI iN-pL-uiMATont Diseases or the Colon
WII COLONfC STASI'. and Obstrcction
\A 111 rmiouRs OF THE Colon
\\I\ DiA-ERnccLms of the Colon
\\\ The Rectlm an-d Anhs
PAPl 7 110
mLIAR\ TRACr
\.\\ I \naTOMA \>D PlftSIOLOOt
\\\ II TEClINTyrEFOR \ BA\ EnOHNATION Ob TJItBlUAPt TpACT
\\\in Tut Pathqlooical Biuara Tract
PIPT TUJhE
THE ABDOMEN
\\1\ Tup Lnrp Silfen Pancbfas and A^dpenvls
PART rovp
FEMALE C.LMTAL TR\CT
\\\ \.RA\!s IN G\NXCOLOCt
PART rnt
OBSTETRICS
WM ,(FNin\i TECHNiQtr
\\\1I Ducnosis OF I n?oNANc\ \Ni» AIatlpnal Peixtc Df
Tm.s?prrfN
N Win PaI lOIXX’lfAL PtL'I'tETPY
W\I\ (rrnALOMETPt
\\\\ TuE llADlOLOClCAL tsTIMATION OF FcETAI AL\TI PITt
\\\M luFltrixs lovmoN IpmFNTmoN AND \BNorMAimE.'»
NWMI llVCENTA Pp-?->-IA
273
223
230
241
2oa
207
277
28o
2t)7
304
31S
320
343
307
3S3
3SC
302
401
400
412
430
Index .
447
VOLUME n
PART OXE
ALIMENTARY TRACT
BY'
S. COCHRANE SHANKS, M.D , FRCP., F.F.R.
A TEXT-BOOK OF X-RAY DIAGNOSIS
PART ONE
SECTIOX I
SALWARY GLANDS, PHARYNX, AND (ESOPHAGUS
CHAPTER I
THE SALn’AKT GLANDS
ANATOMY
The Paiotld Gland bes in. the side of the face immediately below and in iront
of the ear Its relations are as follows Above, it is bounded b} the zygoma ,
bohmd It lies the stemo mastoid muscle , in front is the ascending ratnua of
the mandible It extends below to a line dran n between the tip of the mastoid
process to the angle of the jan It send*; a deep extension downwards to the
pbaryngeil nail, but most of the gland is superficial
The duct of the parotid, Stenson’s duct, is about 21 inches m length It
begins bj the fusion of numerous branches m the antenor portion of the
gland, and runs forward on the mnssefer muscle At the antenor border of
that mu‘5cIo it bends slnrplj inwards, pierces the bucemator muscle, and runs
fon\ard under the buccal mucosa to open in the mouth opposite the second
molar of the upper jau Acconlmg to UamiUon Baihy, Sten^on’s duct is
de^ Old of musculature A small Iol>e, the socia parotidis, extends fom ards
along the postenor part of the duct
The Submaxiiiary Gland hex m the submaxillarj’ tnangle m the neck,
rrom a radiographic point of view its important rclationslup is that to the
mandible Tlie upper half of the gland lies under the mandible, against the
submaxilhrj fos'^a on the inner surfeco of that bone This point is of inijiort-
atice uhen looking for a submaxillary calculus in a lateral radiogram The
submaxillarj duct, Wmrton’s duct, begins by the fusion of several small ducts
at the upper border of the gland It is about 2 inches in length, and nms
forwards, inuanls and upwards to open in the floor of the mouth, m a papilla
on the plica sublingualis close to the fnenum lingu'e ^Miarton's duct is aI«o
x. B ii — I
ALDIEXTARV TRACT
de\ Old of muscular tisaue Its ^ all is nmcli thinner than that of Sten<5on s duct
The Sublingual Gland la small and almond shaped Ithe^iunderthe mucosa
of the floor of the mouth Its antenor relationship is the inner surface of the
mandible' clov^ to the sjTuphj'is Its e-rcrctorj ducts, the ducts of Rivinus,
are from eight to tu enty in number The majority of them open on the crest
of the plica subhngunhs One or tuo jom 'ttiiarton’s duct This last fact is
of importance m sialography of the subma'cillarj gland The cannula ma\
pass into ont of the'yj ducts and the injection fail to reach the intended gland
RADIOGRAPHIC TECHNIQUE
The tahvatj glands may be csanuned m a plain radiogram or after the
injection of a contract medium Tlie u«efulnes3 of the former method is
limited to the demon-tration of salixarj calculi For the demonstration of
an\ other le«ion of the sabvan. apparatus contrast medium radiographj —
sialograph} — lo reqiurcd
The phin radiograms necessart depend on the site of the calculus If it be
in the parotid stereoscopic lateral radiograms should be taken centring oter
tlie gland with the neck somewhat extended and the mouth half open
For the demou'iration of submaxillar} calculi stereoscopic literal radio
erarn-- hhould Ik* taken and n\>o a submental view -with an intraoral cassette,
or an occlusal dental film
The stcrecwcopic lateral Mens should lie taken with the mouth closed and
the head extended The central rat should be directed towards the suspected
ghnd with ft cepKahe mclmation just enough to atoid supenmposition
of the two honrcintal rami of the mandible For the intraoral view the so
lallwl occlu>vai dental film of size 2J bj 3 mches should be usetl cither
plain or in an intraonil inloiT<iftnng screen ca««otte The cassette or film is
intnxUiceti ns far into the mouth as possible the teeth gentlv c!o«od on it and
the central ray directed underneath the chin as nearl} normal to the plane of
the ca-'sette as possible
The technique for the tubmaxillar} gland also sersct. for the sublingual
In the tasc of the sublingual the intraorni film of particuhr imiKrtance
SIALOGRAPHY
''mlogrnphx maj Iw defined as the TadwgrapliK demonstration of the saUxarv
ducts and alveoli bv means of the injection of a radiographic contrast medium
Historical — />ar«)«i/ was the first to pubic h a cx«e u«ing jiotassiura
hhIkIc 'v vend ca*<** wen* then reported with hpiodol a.s the contrast medium,
nutl in 1031 1 } T Payne gi\e a full account of the technique and indications
and dis«cnl>e<i four cases In 1031 Pyrah descnWd the sialographic picture
in four case's of thrcmic jiarotitis
Indications — ,, ©f \alue m the inresti«.ation of abnormahties
m tie ducts ^.ahran calculus fistula sialitu and tumour- of the parotid and
THE SAUVARY GLANDS
3
8ubma\iUar> glands It cannot be applied to the sublingual, for A^ant of a
large enougli duct
Technique. — Provided all manipulations are gentle, sialography is a safe
procedure So far no untouard aftereffects have been noted, and there is
reason to boheve that the introduction of hpiodol into the glands in cases of
chronic siahtis has a therapeutic effect
Apparatus — The essential piece of apparatus is the glass cannula This
is easily made from 3 mm glass tubing One end of this is drawn out to a
fine point 1 mm or less in diameter The end should he flamed to round it
off, if the flaming process be overdone, the lumen is apt to be sealed off
Tius may be prevented by blowing through the tube dunng the heating process
A senes of v ary ing sizes should be at hand The glass cannula is connected
to an ordinary 5 c c record aynnge by a flexible rubber connection The
rubber connector piece of a uretenc catheter is usually eflScient, but the force
needed to join the cannula and tlie record syringe into the connector piece
may disturb the cannula in the duct and it is better to use a rubber tube
attached to a bayonet catch synoge nozzle The cannula and tube must
be filled uith hpiodol before msertion, to prevent air being driven into
the duct
Payite recommends the use of an angled glass fountain pen filler, the pomt
drawn out into a siutable cannula This works \ ery satisfactorily except m
cases vhich requite rather more pressing than can be exerted by the rubber
bulb of the filler
As an alternative to a glass cannula an olive tipped silver cannula may be
used This IS made nith a standard needle butt for direct attachment to a
synnge It is essential that the olivary tip be properly rounded for fear of
damaging the dehcato duct uith a sharp or rough pomt This can easily be
\ enfied under a microscope
Preparation of the Patient — A mild antiseptic mouth u ash should be uced
immediately before the injection In order to bnng the duct onfiee into clear
view, the gland should be massaged Failing tins, the patient should suck a
slice of lemou
The In|cction — This may be given either with the patient sitting up or
lying down on the \ ray couch bitting up is the more comement The
cannula, filled vnth hpiodol, should be introduced for about 4 inch down the
duct, and tlie injection of | to ^ c e slowly given It may take a minute to
fill tlie gland satisfactorily Pam in the gland is an index that enough has been
given After the injection has been completed, the patient may keep the
cannula m situ in tlie duct by clo'^mg the lips gently Tins procedure marks
the site of the orifice, and enables a further injection to be made if the first
'has not filleil the ducts and alveoh completely
The Radiograms — Lateral stereoscopic radiograms should be taken m the
jiositions described under plain radiography Stercoscopv gi'cs so mucli
ALntENTARl TRACT
dearer an idea of the disposition of the ducts and alveoli that a single radio
^nm should not bo considered an adequate investigation
In cases where the interpretation of the sialogram is doubtful a control
investigation of the sound side ma\ bo of help The radiograms should be
taken eviiedjtioiislv as possible Tlie Jipiodol tends to percolate into the
alveoli after ton to twentj minutes and to blur any ndiograms taken after
too long an interval Ihe hazj shadows of the minute alveoli obscure the
c utliiics of the fine ducts
SALIVARY CALCULI
The presence of a calculus is the onli abnormalitj which can be demon
etratecl bv plain radiographv and i confident opinion negative or positive
can be gnen radiologicallv because of tlie dcnsitj of the calculi Thej are
oomivovd of calcium carbonate and calcium phosphate often m alternate
hvern and cast a relativclv dense shadow AH but theverv smallest should be
detectable in a satisfactorv radiogram
The submaxillar} gland is iiiutli the coimnonest site of calculi According
to H akeletj the relative frequenej in the three ghnds is as follows
Submaxillar} 03 per cent
I’fttotid 21 per cent
Sublingual 16 jicr cent
Calculi mav occur cither in the duct or in llie gland The duct calculi
arc oval or elongated rather rough in surface he with the long avis m
that of the duct and mav show lamination (Figs 1 and 2) The} ma}
attain the mzc of a date stone and more than one ma} be present
Tin? pLind call nil tend to be round in contour ma} be single or multiple
ami mav n ich the sire of a green pea (Fi" 3)
THE SALIVARY GLANDS
5
Although the above charac-
teristics and the position of the
calculus relative to the bony
landmarks may be some indica-
tion of its site, sialography
gives accurate information, and
in addition will indicate the
degree of the essential jctio-
logical factor, the assooiate<l
eialitis. This additional method
should therefore be used in all
cases of salivary calculus.
Differential Diagnosis. — Two
structures may be mistaken for
a salivary calculus : a calcified
gland, and a localised area of
bono sclerosis in the mandible.
The latter especially may
Fto. 3. — I..ar(:e siibmaxilUry cabulus.
simulate a calculus in a plain lateral view', but stereoscopy and the occlusal
film sliow its tnie nature.
ALntEXTAR\ TRACT
THE NORMAL SIALOGRAM
In tlie pirotul hi-ilogram tlic duct is narrowest at the buccal onfice and
rapidly widens out to a bre of about a millimetre The bend which it
takes ns It dip^ through the buccinator muscle is usualh nsible On tricing
the duct back to tJje gland a large branch duct forks upward — the duct of
the «o(n parotidis The dutts of the mam gland are man) and tend to join
thi main duct at right angka gi^mg an appearance like a double comb
Th(‘.e sub i liarj ducts break up into fine twigs No tcnninal gemmules or
dihtatijn*« are in-ihlc In the submaxillar) sialogram the duct lumen nia\
tie lir^cr m bore— up to 2 mm as a result of its thin distensible wall
t s-ironip naitw oI tl** jaroi I tie o — {'wiogram ofa m xcd tumour of
ilan I S alotrani Khouine ipm n*l Hat* the parol 1 Note thi fill n^. defect of tie
l> n« of tl r lufi* or e nIertA h vp|>er part of the pland
The secondaia ductules nre less regular than in the parotid but otherwise
prestnt a fiimihr oppearanct (Fig -1)
Sa!ivar> Fistula* —Hr mien al fiHultf aie of no unixirtance since the\
tauv* the p.iticnt no inconTenicncr
tl/ tt f cj-ff Dial ,l r the ^Wnd lutula usualh heals rapidh under simple
trt itniciit and the onh one of radiographic interest is the fistula of
''lensDO s tluct
It .IcMinil lo to dcmo.L-,tnitc «itli tiliat part of tl.e duct tlic fistula com
mum utt. ,iiua the ticanr to Ihi gland it is flic more ilifiicult the treatment
THE SALIVARY GLANDS
7
Tiie fistulous opening on the cheek should be marked \nth a fine Mire nng and
the duct injected with lipiodol through the anatomical ostium If the duct
distal to the fistula bo stenosed, it may be necessary to make the injection
through the sinus An attempt should be made m each case to fill the nhole
duct up to the gland
Chronic Siahtis — It is m tlus class of case that sialography finds its greatest
sphere of usefulness The radiographic appearances afford evidence not only
to diagnosis, but also the degree of the inflammatorj process and consequently
the prognosis Changes may he e\idcnt both m the duct and in the gland
The duct changes consist m dilatation, with, possibly, localised constnctions
The thm-M ailed Wharton’s duct is more prone to dilatation than Stenson’s
Tlie gland changes consist in progre3si\ely increasing dilatation of tlie duet
terminations Commencing in an early case as minute buds the size of a pin-
head or less, they gradualJj enlarge to a size of 1-3 mm m diameter m long-
standing cases To tins change tlie term sialectasis has been appbed The
condition shovrs a close radiograpluc similarity to bronchiectasis (Fig 6)
Of the tiro changes, the terminal dilatation — sialectasis — is the earlier, and
the essential The duct dilatation occurs less frequently The cause of the
sialectasis is not proved, but a plausible explanation is chronic back pressure
from plugging of the duct inth tenacious mucus or muco pus Indeed, the
sticky nature of the resting duct contents may be seen clearly in performing a
sialograpliy On giving lemon to suck, instead of a rapid and free discharge
of ivateTj' saliva, there may be seen a delayed, sluggl■^Il pouting of the onfice
by the extrusion of a bead of thick mucus
Salivary Gland Tumours — Although the nature of these tumours — i e their
salivary gland ongm — is usually eviilent clinically, if there be any doubt, a
sialogram may be of help The parotid gland tumours lend themselves best
to this form of im estigation A filling defect is produced by the tumour A —
sloM-gromng benign tumour tends to push the ductules on one side, and a
deformity of tins type may be evident A rapidly growing invasive neoplasm
destroys the ductules in its path, and m this case the sialogram shoivs an
absence of filling of these ducts (Fig <1)
Mikulicz’s Disease — According to Payne, the sialographic appearances are
normal in this condition
CHAFTER II
THL ^ORAIAL PHARYNX AND (TSOPHAGUS
ANATOMY
As the phari/tir la ojien to direct inspection \ raj examination is rirelj called
for except in cases of pharjngea! diverticulum and post cricoid carcinoma
In a lateral view all three portions of the pharynx ore visible bj \ irtue of
the air contained therein Tins air space is contmuous in the naso plmtynx
nifh the nasal cavities In the oro pharvnx it is bounded m front bj the
tongue if the mouth be clo«ied In the laryngo pharjTix it turns forwards and
narrows into the krvngoal vestibule and can be traced down mto the trachea
Tlio lower part of the larjiigo pharj nx below the larjngeal opening is a
potential space onlj m the resting subject Tlie jiostcnor botmdarv of the
pharjiigeal airspace follows the curre of tho cervical spine and an> preverte
bral swelling such as a rctropharvngeal abscess is clearl> visible Anterior
to the pharynx are two landmarks — thehvoid bone and below it tlje thjroid
cartilages usually calcified in adults and so visible Frequentlj the epi
glottic shadow is visible separateil from the base of the tongue by the
vallecula
The a^ophagu* a nuisailar tube is about 9 to 10 inches in length It
licgiiis at tile upper border of the cncoid cartilage at tho level of the 6tli
rerviPal vcrtehri and descends in front of tho vertebral column passes
througli the cesopiiageal opening of the diaphragm to end at the cardiac orifice
of the stomacli opposite the eleventh dorsal vertebra Its general direction
IS vertical and median but it curves slightly to the left at the root of the neck
becomes median at the lev el of the fifth dorsal vertebra and again dev lates to
the left as jt reaches the diaphragm It aUo presents antero posterior curves
corresponding to those of the cervico dorsal spine
Certain of its relationships are of radiographic imixirtance In the thorax
p'T-vses’ ^rtnVfiTc? fAe ffoftm rtfvA sepuntCec/Zhimif fA’efracAeit f^ren tfescemJs
in the posterior mcdiastimim at first to the nght of the descending aorta then
m front ami slightly to the left of it In front tiie left bronchus crosses it and
l>eJow this it ih in reJafionship to the left auncle
In the abdomen it runs in the cesophagcal groove on the posterior surface of
the liver This i>ortion w short I to I inch m length
The lumen vanes shghtlj It is narrowest at its two sphincters the cncoid ,
and canhae and is shghtlv narrower opjwsitc the aortic arch It presents a
slight Imlb or dilatation immediately above the diaphragm
6
THE KORALAL PHARYNX AND (ESOPHAGUS 9
TECHNIQUE OF INVESTIGATION
The essentials of tJie X raj examination of the cesopliagus are to ohsen e
the passage of an opaque medium along its lumen under the fluoroscopic
screen, and to take radiograms thereof as a permanent record
For routine examinations tlie patient should if possible be examined first
m the erect position The chest should first he screenerl to exclude gross
abnormalitj , and the patient then turned mto the first (right) obhque position
Tins bnngs the nhole of the oesophagus into clear new as it descends m the
posterior mediastma! space On a bolus of opaque cream being sw allowed, its
course is observed from the mouth to the eanhac onfice If a suspectetl lesion
be not demonstrated by a barium cream, a banum paste or biscuit maj show it
Follomng the screen examination, at least two radiograms of the vrhole
extent of the cesophagus should be taken, each immediately after swallowang
a mouthful of the cream Frequentlj more arc necessarj to determine the
constanc) of an abnormahty The exposures should be as brief as possible,
111 order to avoid transmitted cardiac movement
In cases of gross obstruction further radiograms at intervals may he
advisable, and at times the left obhque new may be of value
Although the above procedure will show the inajontj of oesophageal lesions
satisfactonlj , it is often nece««ary to examine the patient in the horizontal
position, or the Trendelenhtiig in order to demonstrate the upper and lower
limits of the lesion Again postero anterior, hteral and/or left obhque views
are at times neces‘'arj to demonstrate the exact site of a pharyngeal pouch
A postero antenor view similarly demonstrates the lower end of the ceso
phagus m gross a?‘>ophagectasia from cardiospTsm
The Double Swallow Method — ^TlmisofuseinEhowingtlicupperandlowcr
limits of an oesophsgeil lesion especnllj carcinoma The patient swallows
some ounces of a thm banum cream After this has pxsacd into the stomach
lie assumes the right oblique Trendelenburg position If the patient m this
position swallows another mouthful, the cardn relaxes and alloivs regurgita
tion mto tlie ce^ojihagus A bolus of thick cream is then swallowed, to outhne
the tipper limit of the leMon The method js not alw aj s siicce'^ful ns regurgi
tation niaj not take place but even if there is no reflux the normal transit is
slower, and more likelj to outline (he lower limit of a stenosis In cases of
carcinoma in which it is proposed to insert a Souttars or other tube it is of
particular value, and should be tned if simpler measures have failed to demon
«tnite the full extent of tlie narrowing
The Opaque Media — ^Tlie particular fonaula u«ed for the banum cream is
unimportant, provided it contains a sufficiency of banum and is of the proper
onsisteucj , that of a thick uniform cream If the ccsophagtis only requires
ivcstigntion anj excipient may be used cfcreal , Benger’s , mucilage If,
owever, ns is froquentlj the ca-se, the stomach also is to be studied, the cream
10
ALIMENTARY TRACT
shouki be suitable also for that organ and it is the w nter s custom to use a cream
the same ns for the stomach This can be made tlncker if found on preliminary
examination to he necessarj , bj the addition of banum sulphate powder
The formula u«ed bj the xrriter is ns follows
lianum Sulphate % 10
Raecl nrino firs 2
Gum TraesPiinll Rra CO
Cftsen c of na-apbeiTv 11^ -It
\q II I SI
A satisfactory jnste is formed by mixing equal parts of the above and
pondered barium sulphate
iJuriMwi — Several satisfactory brands are on the market These
are of ti«:c when it is desired to excite xn intermittent spxsrn of the msophagiis
Tiie biscuit should be swallowed with as little mastication as possible but it
should he borne in mind that if swallowed too dr\ it may stick m a normal
oesophagus for quite an appreciable time
The Canum peKef usually m the form of a banum glycenne suppository is
still more erratic m its beha\iour It may remain immobile m the normal
oesophagus for many seconds or exen minutes and in a case of obstruc
tion may lio arrested some distance abo\e the site of the lesion In such a case
a mouthful of water will cau«e its descent to the actual site of obstruction
Banum 11 oo/ — ^This consists of smill pledget* of wool soaked in barium
cream and is of xalne m showing the site of an impacted iiahbone or other
transiiarent jiGinted foreign bod\ in the oesophagus
Banum cream JoUoired by water mas be of xalue m certam case* of impacted
foreign bods (171 )
An important point m technique is that if obstniction he present a thin
cream should always be used first The u^e in the first instance of a paste or
bi'cmt IS liable to cause the patient some distress if the stenosis be marked
THE PHYSIOLOGY OF SWALLOWNG
A F Barclay has made an admirable and very complete X ray study of
the process of deglutition and the description below is based on the very full
account he has recently puhiisheif of Ais research
He studied lluoro'-copicallj and by semi radiograms the act of deglutition
111 a large number of normal subjects
Briefly the sequence of events a-s he describes them is as follows
( 1 ) lnE I rises
(2) Tiir I*nAR\^OB.\L Space becomes obliterated for a fraction of a second
immediately before tlie food is propelled backwards over the tongue
(3) Thf Piiarwoeal ^pacf then opens to recci\e the bolus which is
mpidh shot into it and down into the upper tlurd of the cesophagia The
THE NORJIAL PHARYNX AND (ESOPHAGUS
n
food IS seen bj the fluoroscope to piss do^^n so quickly as to suggest that it is
sucked dou n
During the act of snallomng, all three phar5Tigeil opening, nasal, oral,
and larjiigeal, are firmly closed
(4) The R6lb of the Epiolottis is a cunous one It as formerly held
that the epiglottis acted as a cover to the laryngeal vestibule Nothing of
this nature takes place and apparently the chief function of the epiglottis is to
form, u itii the \ allecula in front of it, a trap for saliva passing dovn the back
of the tongue betu een the acts of deglutition
During deglutition the epiglottis is pressed against the posterior plnrj ngeal
V all m the closed phase In the open phase, hen the bolus is bemg shot back
into the pharynx, the epiglottis projects upwards, free of both anterior and
postenoi pliaryngeal walls, “ hkearock projecting upwards imdcrawaterfall ”
as liarclay puts it Normally food pisses over it into the pharynx, but
Qccasionilly a small portion is trapped by it and lodges in the i allecula,
thence to bo dislodged bj a second act of an allowing
(5) The Closuhe op the Naso Piunrvx results from the combined action
of the superior constrictor of the pharynx and cIe^ ation of the palate
(C) The Tonohf clones the oro pharjTigca! opening
(7) The CLostmB of the Iahynoeal OnmcE is a complicated process
Firstly, the laryngeal vestibule' is obliterated as far as the false \ocal cords by
ft protrusion of the ba«c of tho^tongue backwards and downwards between the
liyoid bone in front and the' epiglottidean bise behind The hyoid rises and
appears to “ swallow " the base of the tongue Secondly the anterior wail of
the laryngo pharjmx ijses behind and on either side of the laryngeal \estihule
and further occludes it The muscular action involved m this last proces«
IS obscure but the anterior pharyngeal will below the laryngeal vestibule is
very loosely attached, and this radiologicil ob««rvation is certainly possible
anatomically
A final paradoxical observation m Barclay’s research is that the ^ estibule
of the larynx appears to open up as the hyoid bone descends and just as the
jfondasailinntJn/iaRs/lown behind at
The abo\e complicated act of deglutition is continued into the upper thml
of the oesophagus Below tliat level the penstiUic action of the oesophagus
takes charge In other words, the chain of reflex action includes the upper
part of the ossoiihagus
Tlie rapidity of the transit of the food m this reflex was investigated by
Bardai/ in collaboration with Anrep, and they came to the conclusion that the
food realiv was sucked down and that there is a negative pressure in the lower
phirynx and upper cesophagus They found, on passing a rubber catheter
into the upper oesophagus and connecting it to a raonometer, a negative
pressure of lG-18 cm water when bread was swallowed
In the Lower Two-thirds of the ocsopliagus the food is impelled downwards
12
ALTME^TAR■i TRACT
a rapid peristaltic wa^ e This w aa e is not deep and does not segment the
bohis It docs not produce an occlusuo penstaltic nng and if obstruction be
present below some of a fluid niediiim is squirted up through the nng to
simulate i-everso penstalsis True
reverse peristalsis does not appear to
occur in tlie cesophagus
The action of the cardiac sphincter
is variable in tbe normal subject
Sometimes it appears to act as a
patulous canal and at other times as
a sphincter responding to the inliibi
torj impulse of a peristaltic wave in
the ojsophngus
NORMAL X-RAY APPEARANCES
In the erect position the banum
cream can be seen to pass smoothly
down the oesophagus in a rapid
peristaltic w ave In the right obhqut
view Its course is doun the posterior
me<liastunim with the dorsal spmo
behind and the aorta and heart in
front It follows the cune of the
spine separated from it bj about an
inch Tlie aortic arch indents it
slightly — the aortic impression
In addition to the aortic im
prcssion there are described three
other slighter indentations of the
avipliagus caused from alovedown
wards by the left mam bronchus
the left aiincle and the lower end
of the thoracic aorta These are of
importance m cardio vascular disease
and are considered in detail m that
section (Fig 7)
til — Nonnal nopl am < m
anlrr or obi j e > ew
ll p rikl I
In both the first oblique and
postero anterior views all four im
pressions are contave to the left
Ihe cpsoplingeal lumen as v tsuahsed b^ the opaque ertam vanes soincw hat
at difTcrcnt levels Hie aortic impression causes an apparent narrovnng
From this point the lumen becomes wider down to the diaphragm Just above
this it narrows and finallj tajxrrs towards the cardia
THE NORJIAL PHARYNX AND (ESOPHAGUS J3
The rate of transjt through the (esophagus depends, in the normal subject,
on the po'^ition of the patient and the consistency of the contrast medium
In the erect position, inth the cream abo^e described, the average time is tiro
to three seconds This time is lengthened with thicker media and with a dry
biscuit ivhich has been swalloned with httle ensihiation the time may be
thirty seconds or even a minute or tno
The supme posture increases the time of transit with the standard cream
up to four to si'^ seconds but not that of the thicker medn
Frequently a small residue remains m the lower ojsopliagus, after the
sualloMing of a bolus of the cream It shons as a thin streak or senes of
longitudinal stnee above the level of the diaphragm, which gradually dis
appear after a short intenal AVlien a quantiti of thin cream is swallowed
qiucklj the lower part of the oesophagus may fill up to a considerable extent,
e g the whole of the lower third, and then empty suddenly into the stomach
In the postero anterior new most of the oesophagus is partlj obscured by
the mediastinal cardiac, and spinal shadows This new of use in examining
the last few inches of the oesophagus, and in the investigation of di\erticnla
and cardiospasm
CHAPTER III
DISEASES OF THE PHARYNX AND CCSOPHAGUS
DYSPHAGIA
The rast majority of cases referred for a*sophageaI evanunation are so referred
on account of dvsphagia and X 013 investigation affords the most accurate
and the safest method of deterroining the presence site and 15^)0 of a lesion
cnusiD^ that 8\mptom Before considering the \anous types of cesophageal
obstruction certain general considerations are worth} of note The N ny
appearances under the fluorescent screen \ar3 considerably according to the
stage and site of the obstruction
Stages of CEsophageal Obstruction
First ST\rE of Simple D58phogia — Li thw there is no pam little dilnta
tion and little obstruction Fluids ma} pass and only thicker media cause
nn\ discomfurt
Sfcond ^taoe that of painful dysphagia Tlie patient beginning to lose
flesh definite dels} m the rcsophagus with powerful peristalsis and refluv of
tlio mc<Iium
Third th© stage of atomc dilatation and stars ation of the patient
Tlie cc«K)phagus gives up the struggle and acts as a resersoir Banum tna}
remain in it for hours
Variations in the Picture according to the Site of the Obstruction
In OnsTBi ction in thi. Upfer Tiord the d38phaj,ia is marked The act
of deglutition itself is diflicult the banum is rapidl} regurgitated the epi
{lottic \allcculn pvnfonii foss-e and liiynx tend to bo coated with Innum
and some of the medium freqnentl} pa'isos into the trachea accompnmed by
coughing and distress on the part of the patient There i-, little or no dilatation
in the a«ophagus proximal to the o 1 stniction ns little of the contrast medium
is retained therein
In the Mrnoi r T hird there w less difficult} m deglutition les-, tendenc} to
distressing rcgurj,itation and more diintation of the ccsoplmgus
In tuf Lowfr Third the (esophageal dilatation is at its maximum,
di comfort at its minimum and retention of the opaque cronm above tlie
p< mt of obstruction la considerable
\t an} p\cn jioint tbt degree of dilatation Mines according to the t}'i)c of
lesion Tims it is greater in benign than in carcinomatous steno is and
u
DISEASES OF THE PHARYNX AND (ESOPHAGUS
15
reaches its maximum m sp-vstic conditions, cardiospasm being tJie extreme
example It also varies directlj with the degree of narroiving
PHARYNGEAL DYSPHAGIA
In a number of conditions in the phar^mx there maj be a considerable
dysphagia quite apart from anj obstruction m tbe oesophagus Amongst the
causes of this are bulbar palsj , plnryngeal pouch extrinsic pressure on the
phaiynx from tumour or prevertebral alwcess liypophar3’ngeal or post cncoid
carcinoma, acute tonsillitis or other type of ‘ sore throat " Plummer Vinson
sjTidrome or even simple nervousness
The X ray appearances on swallowing a mouthful of banum are the same
as those of high oesophageal obstruction (or more exaggerated m degree),
except that as soon ns the barium readies the cesophagus proper it pisses
douTi normallj In addition, some of the aboxe causal lesions show special
radiographic characteristics w Inch render them recognisable
Extrinsic Pressure from prevertebral abscess or tumour is xnsible in n
true lateral picture of the neck encroachment on the pharjoigeal air space
In the former, the fonvaixl bulge of the posterior pharyngeal wall is
Tcadilj recogmsable
Pharyngeal Diverticulum — ^The rare fonffevUal ^o$t lonsiUar dxxtrlicnla
arising m connection with tbe second branchial cleft are not susceptible to
X raj demonstration and require no consideration
Tht deep pharyngeal pressure dneriteulum is a much commoner lesion and
IS clearly clemonstrited bj X ray examination These diverticula, still
commonly referred to as oesophageal occur on the posterior wall of the
pharynx, about I cm above the up^ier end of the msophngus at the pharjoigeal
dimple This dimple, median in site, marks a small gap between the oblique
and transi erse fibres of the inferior constrictor of the pharynx, and the pouch
commences as a herniation of the mucosa through that gap The commonly
accepted view of the mechamsm of dexclopment of the poudi is that repeated
forcing of food into this pocket durmg tlie act of sw allowing gradual!} enlaiges
this pouch doivnwards until a diverticulum of large dimensions may result
The opening of the pouch is median, transverse and sht hke and mav reach
an inch in length This theorj is at variance with Barclay s theory of the act
of deglutition, described aboie, and lie su^ests that adhesions of the posterior
phaiyngcal wall to tbe preiertebral fascia behind may bo the cause The
pouch, when empty is collapsed m the coronal plane and as a rule hes in the
mitlline but as it enlarges max deviate somewhat to either side, more com
monlj to the left
X nA\ ArpEARAXCES — In tbe right or left oblique position the contrast
medium ihsocu to pass down into a rounded flask shaped pouch, and then to
spill oicr anteriorly down the oesophagus Frequently the banum cream
pa«Kcs> into iKith smmltaneousK In eaily cases wnthout marked syanptoms.
ALDIENTARY TRACT
in \\hiph the pouch is small it maj retain a residue or raaj remam quite full
without discomfort and emptj \ei3 gradually A pharjngeal pouch does
not as a rule cause tesophageal obstruction bj extrinsic pressure E\ en when
large the djsphagia is caused b> o\erflow eniptjmg of the filled pouch into
the pharynx resulting in Imuhing and choking until ifc is partly emptied
A pool may be left for some time in the fundus of the sac CharacterLstically
the banum filled tiouth show s n horizontal fliiul lev el and a successful radio
Fic S — Two fiwxM of [ I aryncrcal | oucl
gram of the condition should show a stream of barium cream passing down
the fesophagus m front of the shadow of the poucii (Fig 8)
The size of the imuch mav varj from 1 10 cm across and one of the latter
dimensions mav have a capacitv of os much as 4 5 oz The contour of tlie
hsnum filled sac is regular and rounded unless food remnants are already
pre-'cnt therein The outline of the sac ni the postero anterior vuew is occa
fiiouallv bilocular taking the shape of an inverted conventional heart
Carcinoma mav develop m a ]>ouch and l>e visible as a filling defect :
DISEASES OF THE PHARYNTC AND (ESOPHAGUS
17
This vieA% IS of value in determining to m Inch side -v diverticulum deviates
if at all , a point of importance in case of operation
Traction Diverticula are very rare The> result from the traction on the
msopliagus from contracting extrinsic scar tissue According to /? S Paferson
(Fjf, 9) the> are
usually situated on
tho right anterior
wall of the ccsopha
gus and are horizon
tallj disposed Thej
are thcrefoie best
vieued m the left
oblique position
They fill better ^\lth
the patient Ijmg
dou-n The great
majority of them are
83nipto]nless bii t
Paierson records that
dysphagia regui^ita
tion and sub&ternal
pam hn^e occurred
from impaction of
food in the pouch
Those uhich are
epiplircnic and
epicardiac in site
maj he associated
a\ith daspliagia and
cesophagectasia
(Schui )
, Hypopharyngeai
and Post CTicoid Car
cinoma — A true
lateral position — Conge tal jortal florae stomach with short
should be used in ff~foplagm and a small tract on 1 vert rulum of themaophagus
imcstlgating this vmbloonlj m the left oW quo s p ne «en
condition Tho
djsphagii IS markeil and the sequence of eaents so rapid as seen under the
lluoroscopc after an opaque swailou that little can be seen beyond tliat the
opaque medium docs not pass smootlilj into the cosoplngus Regurgitation of
some of the banum is common usually bj a coughing reflex TIio latter is
induced by escape of the cream into tho larynv A mdiogram tahen after an
X R 11- 2
18
alimentary tract
opiqtio bolus has been swaUowwl will fcliow irregular fragments of barium
entangled in the growtli, and probably some coating with barium of the
lallecula, pjnform
fosioj and e\tn larynx
and trachea
A lateral radio
gram, taken without
ani opaque swallou
sometimes gnes quite
a rbaTncteTJ'stie pc
turc Ihe tumour
projecting into titc
hypophnrjnx en
croaches on the air
space and its oiitbne
IS thus shown up in
lehef Tins applies
particularh to a
tumour growang from
the posterior wall
(Fig 10)
Plummer-Vinson
Syndrome. — D^ajiha
gia 13 a common s} mp
tom m this condition,
resulting from atrophy
of tlie buccal and
j)har\ngeal mucosa
and spasm or achalasia
ofthocnco pharyngeal
sphincter The radio
til 10 — Earl) pOKt rnconlcarrmoniA eaiiAin(!a]ieht<f>i>ophQgf>al graphic picture IS
oNiniption ftn I piv««ing on the j)oa<e«or»«llof tlw (rachra 111 C T 0 1 y that of
pharyngeal dj sphagia,
and the diagnoMv u\uf.l rest cm tluj cUmcal and U«.w\atwlwgica\ featwtes
CONGEMTAL MALFORMATIONS OF THE CESOPHACUS
lliesc are \era rare and arc usually incompatible with life According to
llAipAam and Fag/jt tiie following lin\c licen rocortled
Coitgemlal ahitnet
Congenital atresia, with or without trocheo oesophageal fistula
Congevifal Meno^is of tiie lower end
JhfuTtation, muting at the lower end
DISEASES OF THE 1>HAKYN\ AND (ESOPHAGUS JO
The svmptomfttoIo 53'3 of tlie obstructive lesions is ver} tjpical inability
to retain fluids regurgitation of fluid througU the nose attacks of dvspiicEa
cough and cjanosis on feeding and broncho pneumonia deh^drition irasting
and death m a neck or so
In cases uhere there is a tracheo oesophageal fUtnla the upper cesophagus
ends belon as a blind pouch* and the lower cesojihagus commumeates above
with the trachea iisiialh at the bifurcation Gas therefore reaches the
stomach and intC'^tinc via the trachea and lower gullet The radiographic
diagnosis rests on the demoastration of « banum filled blind upper a«ophageaI
pouch and a stomach distended with gas Jilaihieit and Goldsmith have
recorrled tw o such ea«es
FOREIGN BODIES IN THE CESOPHAGUS
These maj lie of raanj varieties but f-ill mto two t 3 pes opaque and
transparent The technique for each tj-pe is different
I\ hether a foreign bodj becomes impacted in the gullet or not dejiends on
Its size and shape Smalt rounded bodies pass larger ones and most irregular
or Bpik«l ones even though small usual!) impact The impaction of «ma!l
irregular bodies dejiends on their causing trauma to the ccsophageal mucosa*
mth resultant spa^m
Opaque Foreign Bodies — ^The \anety of tliese winch have been recorded w
legion Coins small tooth plates pins safety pms needles portions of clnl
drens to) a and dense meat bone» are all of common occurrence (Fig 11)
The commonest site of impaction isa little aboi e the aortic arch arid neat at the#
lower end of the oesophagus Impacted fiat liodies eg coins he in the coronal
planes In the trachea they impact Jii the sagittal plane a distinguishing
feature SmaU pointed bodies such as pms or needles ma\ impact at anj site
The) often jiaas into the stoniacli and their impaction depends on penetration
of the point into the ccsophageal wall They form the most dangerous type
because of this liability The writer met with a case m which a Gillette razor
blade became impacted and which resulted m n fatal mediastinitis
The large opaque foreign bodies are easil) detected b\ \ ra) examination
both under the screen and m a radiogram A senes of radiograms rau&t
howe\er be made m e\er) case m which it is suspected that an opaque foreign
bocU has lieen swallowed lieginning with the cesophagus If none is found
therein the whole abdomen should be examined m case the object has escaped
tl rough the cardia It is w no also to make isure h) radiograms that the bod)
13 not in the bronchial tree
Calcification in thecncoid or aiylenoidcartilagesma^simnlatean impacted
bone A distmguislung xiomt is that a banum swallow passes behind them
but the arjtcnoids are so clo'^e to the plmi^mgcal lumen that differentiation
mnj be impossible without phnrjngoscop\
ALIMI-NTARI TRACT
JO
Ircqucnth small bodies aucliaspins cannot be seen on screen erammntion
TJie^ art ahvn;ys M-vjblc Jn radm^ranis of first qnabt\
\fter an opsqno foreign bo<R bos been localised in the cesophagiis a
( I Tl «> bone in thf' frultoi (' ) Bar u n \ oo) pteilset im) alcsl n i the bom
(c) The extmcled bone I Te eiac
t IQ II — Pheasai t bme i npacted m the re of I ajju
mouthful of Opaque cream mat be gnen to detcninne the degree of spasm
or obstniction
Transparent Foreign Bodies — ^Tlie common ones are small or thin meat
and fish htnes and tmlcamtc fragments of tooth plates
As the foreign iio<l\ is not directU demonstrable m n radiogram its presence
DISEASES OF THE PHAR\Tv\ \XD (ESOPHAGUS
21
impacted m tlie ce<5ophagus suggested bj the symptomatologj , must be shoum
by other means «
(1) A bartum cream ma^ demonstrate an obstruction at the site of the
impaction either from the foreign body itself if it bo large or from spasm
if ulceration has taken place Frequently however the cream is seen to
pass dorni luthout am obstruction alien the foreign bodi is small such
as a fish bone
(2) In such a case a small pledget of wool soaked m barium cream should be
swalloued b\ the patient and its course down the ccsophagus observed fluoro
scopicalli It IS given in the hope that it may become entangled m the pro
jections of the foreign hod\ and a clue be afforded to the site of the latter
This test is not v ery certain ns m the normal subject the pa'wage of the pledget
doun the ccsophagus may he slon and erratic A small chafer of opaque
cream may help it down to the impacted body but freqiientlv u ashes it down
post It ‘^ome laryngologists dishke this metliod as it may ob«ciirc the
foreign body
(3) A method Tuinog recommends is to give alternate dnnks of ianurn
cream and icaier Xlic latter clears a normal cecophagus but may not if a
forei„n body is impacted The value of the test i^. enhanced if repetition
several times always gives the <»ame result
CARCINOMA OP THE (ESOPHAGUS
Carcinoma is far and a«ay the commonest intrinsic lesion found in the
ccsophagus It probably accounts for at least 90 per cent of all cases of
dysphagia examined in an X ray department
Types
(1) Squamous celled the common vanetv
(2) Cvhndncal celled arising from the rauro«al glands
(3) Colloid
(4) Diffuse boirthoui
Tlie two latter are rare
Morbid Anatomy — At first limited to the mucosa the growth tends t
become annular in di tnbufion and thus to cause stenosis ’^mall canhffowe
excrescences and ulceration combine to produce a narrow tortuous channei
the appearance of which is so characteristic m a radiogram In time thi
growth infiltrates the muscular coats of the cc^-ophagus and then the me<li
nstinum Perforation is not an uncommon sequela moat comnionh into th^
great vessels le^s commonlv into the trachea or bronchus and rarcK into tin
pleura or lung Metastases are uncommon *
Sites — Although anv portion roav be imoUcrl the site-> of election are thi
narrow portions of the ccaophagus namely tlie upper and lower ends and m tb<
region of the trachea! bifurcation The relative frequency of occurrence a'
each Mte is still a matter of dispute but it i ptobablv commonest at or a little
ALIMKNTARi TRACT
!>eIo\\ the tncheil hjfurcatioii aiwl certainf3 occurs more frequeutl) in the
thoracic than in the cerMCal jKirtion
Radiographic Features —If as is the rule some mrroning of the
DISEASES OF THE PHARYNX AND (ESOPHAGUS 23
taper rather abruptly and irregularly into the stenosed passage, or may
overhang it
This irregul'inty is dependent on the precise contour of the upper part of
the g^o^^ th, and if the latter be of the cauliflower ' tj’pe, quite a large filling
defect may be at the loner end of the dilated portion Tlie stenosed
pas‘>'ige it'self ma\ be from 1 to 4 or 5 inches in length and m the longer
laneties it maj be necc'sarj to cvamine m the horizontal position or to use
TjO 14 —-Two ca.'<cs of olxtructin; ^Brnnoma of tha loviej
the double su allow method m order to demonstrate its whole length In
oa<»es where the stenosis is shorter, the routine examination m the erect imsihon
may serve to show its extent It is of importance to show the sfeno^'is in its
entiret\ if radiotbcnvpj or intubation is contemplated
The most characteristic features of the carcinomatous stricture are its
irregulanta and the constancj of that irregulnwty T!ie barium filled lumen
tipically shoirs spik} projections 'ind angulations, and the banum stream is
frcqnentlj broken uj> into two portions bj an intervening protulierant moss
of grow til, a filhng-ilefect of the stneture itself (Figs 12-14)
ThcMi irregularities are constant allowing for variations duo to xnrvint»
amounts of banimi contained in the stricture
24 ALI3IEXTARY TRACT
Thi-5 constancy is best tested bj the supcrimposition of successi\e films,
caelj taken after swallouini; a bolus of bamim emulsion At least two radio
grams should be taken as a routine
In the rarer ocirrhoua forms of enremomo the stenosis is less irregular, and
thesjnk} jirojections are absent Difficultj maj be e-^penencedm distinguish
mg between a scirrhous
carcinoma and a benign
stneture and in ninnj
ca<ses it is impossible so
to do from the radio
graphic feature-* alone
Perforation of a
Carcinoma — The only
\aneties of perforation
tint reach the rndiolo
psi arc IhosB mtp the
mediastinum bronchus,
or jilcura If into the
mednstinum a banum
filled pocket will be “een
on swallowing provided
the Cfidema of the result
ing mediastmitis does
not compress tlie
tcsoplmgus aboNO the
perforation In ca'-es
where tJie bronchus is
perforated thecmulsion
passe*, into the bronchi,
accompanied bj cough
mg and distress (Fig
15)
If the pleural cavity
bemiolved the barium
cream ma\ flood the
Fi< n — ( an- noma of t) (* liAKitv I rrforattns B trartci 114 plcUra or remain local
Nott barium (ream jii tl bron ) si tree ised 1)1 prc CMStlRg
adhesions
Inti ration and Radum TnrBSn — \ ra_j examination is often required
after the m*<;rti()n of a Souttars or S\niand 9 tube or the implantation of
rtKlofi t^cds A nidiopram taken in the right oblique \iew with or without a
lanumswnllow will show if the tube is in the coirect position (Fig 10) ''uper
imimsition of the film so taken on that taken of the lesion before intubation is
DISEASES OF THE PHARYNX AND 0 SOPHAGUS
25
frequently a help Again suchfilm taken after a bantim sw allow willshowif
the lower end of the tube Ins reached the lower limit of the stenosed passage
If the tube has ulcerated through the stenosis and passed down the cesophagus
or into the alimentary canal below thw w iH be at ouce apparent
It IS difficult in a plain radiogram to do more than enumerate the radon
seeds implanted Their distnbution relative to the tumour cannot be arrived
at although a stereoscopic pair of radiograms may gia e a rough idea If a
l-iQ 10 Care o ni» of the cp«y husus before an I after nt baton v tl a f'outlnr « tube
barium cream bo swallowed just Jiefore such a pur are tal en tl e stenosed
lumen may also be seen stereo copically and help m the localisation
SIMPLE TUMOURS OF THE (ESOPHAGUS
These are extremely rare ra^ugyaj descnl ed the \ rav appearances in
a case of jicdunculited fibroma Hie features he noted indicate the signs to
lie expected in these cases The opaque metlumi is seen on screen examina
tion to be slowed up in a part of the cesophagus which shows no stenosis but
wlkh oil tie contnvr\ mn\ actually appear widened The banum column
20 AL-niCNrAR^ TRACT
ma> be seen to be di\ide<I b> a central clear area — the tumour Tins trans
lucent area may shou some marbling from the adhesion of barium to tJie
tumour surface ami this jiroccsa maj gl^e an outline of the tumour m relief
after the mam mav. of barium has passed on In contradistinction to caret
noma the walls of the cesoplngnsin the affected region show no CMdenee of
infiltration and present smooth contours
BENIGN STRICTURE OF THE CESOPHAGUS
etiology — Simple fibrous stricture of the cebophagus is a late result of
ulceration of the miuosa
1 his ulcentjon is genenilK the result of swallowing corrosiv e fluids or boiling
water Occnsionallj it follows the impaction of a foreign bodv whilst rarelj
it is tuberculous or »y phihtii.
Morbid Anatomy — The formation of the stneture dexiends entirely on tlie
position e\tent and degree of the traiiiha or ulcer which is its cause
In the case of corroMvc fluids the injury tends to bo localised at the three
narrow portions of the ecsophagus although the damage raaj c\tend over a
large portion or the whole of the <x?sophagcnl lumen
Types
— This arises from a localised caustic burn or an ulcer from an
impictcd foreign bod\ It is not common
ft iiiLAR — lliis )« the common tJ^^c resulting from an extensive bum or
nlcenition The muscular coats of the tcMiphagus are fibrosed and a dense
tubular Rtricturc of consider ible length results (h ig ] 7) If the original lesion
mv oh ed the pen n?>ophageaI tissues fibrous contracture may produce displace
limit of Ibc crsopliagus
In untreated cases these stncturcs ina\ incrense m seventy imtil tlie\
f)c< time a! solute
Radiological Features
\NM.L.vn T\i 1 — ^Tlie proximal portion of the cchOphagus is dilated flic
degree of dilatation is dependent on the site of the stricture being greater the
fower the fatter i*! sifuafcu* it is commonh fieW to fie greater than m mafig
nant btricture The dilated portion terminates conically below mtc the
strKiure with ns a rule httlo irregiilanty ami no supra stenotic hllmg defects
The stnoturc itself shows none of the spiky irregiilanties of the cariinoma
tou«vanet\ The-^ strictures may be multiple
Trni uvr Tv pl — Here a considerable jKirtion of the cesophagua may be
narrowed The degree of stenosis ma\ vary from point to point along the
extent of the stneture but as a rule it lacks the irregiilarity of the neoplastic
tvjK* \8 these stnetures usually result from corrosive action the cesopbagus
DISEASES OF THE PHAK\\\ AXD O-SOPHAGLS
27
above the actual narrouuug tends to become fibrosed from a Ies«cr caustic
action and dilatation is therefore absent -Vnj marked denation of the
CDsophageal lumen indicates mediastinal i^bro'^is and contracture
Tlie chief diagnostic difficuUj m benign stricture is to differentiate it
(o)
iic 17 — Two cauM of ben gn efr cl w of 11^ <B%oph«{nis fo) II storj of Iwphaps e nee
ch Idf ooU no cause fou I (* eongen lalj (6) T\ibul<ur a(r cturc three luontha affor ewallo np
»{. nta of salt!!
radiogrnphicalU from the scirrlious type of t'nrcmoma Asarule houever the
matter is settled b^ the historj of prerioiis trauma
Treatment — Fluoroscopv maj be of hi;!p dunng the passage of dilating
bougies a procedure uhich is often diffict|]t
ALHIENTARI TRACT
2S
SPASTIC OBSTRUCTION OF THE CESOPHAGUS
The follo^Mng laaj occur
(1) Cardiospasm
(2) Spasm from ulceration
(3) Spasm from impaction of foreign bodies (This has alread^ been
described )
(4) Spasm abo^e the cardia nitliout obvious organic cause
Cardiospasm (isyn cesophagectasn acholasia of the cardia)
In this condition tlierc occurs o diffuse and considerable dilatation of
the cp'jophageal lumen associated uith a contmction of tlio cardia It is
not n common condition but accounts for the great majonts of cases of
spistic obstniition
PcTiioLOQi — In a uell dcvelopeilcise the folloumg changes uill be found
(1) The cesoplmgua is markedh diluted in its lower part The dilatation
gnidinlU diminishes upviards and is \irtuall^ non evistent in the cervical
portion In no other form of obstruction does the degree of dilatation npproacli
to that found in tins condition
(2) Iho entire muscular coat becomes hj^pertrophied
(3) The asophngus becomes lengtheneil If this he marked the cbso
plngiis maj assume an S shaped contour the lower convexity to the left
(4) In a late sta^e the muscular coat nia\ atioplij the nuicnsi become
thickened and later de^elop multiple ulcers
(5) The canine sphincter is in a state of ti„ht muscular contraction and
tlie mucosa thereof thrown into longitudinal folds There is no actual hj-per
tn ph\ of the sphincter
Ittoioox — The condition occurs particularly m \oung adults of both
sexes with 1 pieponderame in females It may however occur at nn\ age,
and La) ymcaH has desenbed a case in an infant of 1 C montlis
lliere are two theories as to the mechanism of the obstruction Tlie older
^ lew IS tJiat It IS an iiUniisic spasm of the sphincter Acc-ording to I/ttrsf it is
iluc to the failure of the hplimctcr to relax the result of a fault m the neiiro
inuscalir reflex He suggests degeiicmtion of Auerbachs plexus as the
Aawwr fa Lxfxmcof tttis %feit ts the of hypertmphx af the
sphincter and the degree of dilatation aliove m other words a reciprocal
failure of sj hmctcnc inhibition and of i»ropuIsivc contraction nbo^e
Rvdiologicvi FcATtni-s — ^Tbe sinking feature m a marked cus.c is> tlm
asophagectnsm On observing the patient in the right oblique position
whilst he IS swallow ini:, the opaque cream the latter is seen to slide do\vn the
dilated ccsojihagus and then to form a pool at or just below the diaphragm
tlu k\cl rising as tlic asophagus becomes filled Very frequenth the
o* oplngns IS nirendv parth filled with lianspirent contents in winch rase the
DISEASES OF THE PHARYNX AKD Q SOPHAGUS
29
banum \v^U be «een to ‘sink slowly m blobs tlirough tbesse contents to the foot
of the CDSophagua The transparent Amd floats on top of the barium and ls
gradmlh bftecl to the upper portion of the ceiophagus At the junction le\el
of banum and retained contents there is usiiallv some admixture of the te o
pirticuhrly if the latter contains imperfectly masticated food The lower
part of tlie dilated tesophagus is typically conical tapenng smoothly to a point
— the sphincter itself T1 e smooth regularity of the cone is a diagnostic point
If a filling defect I e present m the lower end of the shadow it may be the result
of a food residue This should be excluded by re exanunation before labelling
as a careinonn a case which othennae presents the features of achalasia
As the obstruction is low down tlie dilated cesophagus display s considerable
tolerance to retained contents A severe degree of cesophagectasia may con
tain when full 10 20 oz of fluid and tolerate watbout any cbscomfort 5 10 oz
for a considerable time In many cases there always throughout the day a
residue of some ounces earned on from one meal to tlie next A residue up to
twenty four hours is not uncommon
In the riglit oblique view the pointed termination of the banum shadow
hes below the diapliragmatic domes as these are higher than the oesophageal
liiatus immeohatclv below which the oesophageal sphincter hea Sametiines
a clearer outline of this oUagnosticalli all important termination is obtained
with the patient m the postero antenor position In this new the barium
cone pwnts downwards and to the left and again hes below the level of
the dome In this view again the S curve of gross ce opl agectasm is
liest demonstrated (Fig 18)
The obstruction at the sphincter is never absolute and rareU approaches
to that degree As a rule irhen tlie oesophagus becomes full some of the
cream escajies through into the stomach It is as though aboa e a certain level
or Jiead of banum the «phmctcr relaxes sufficienth to bring the banum
column down again to its threshold height
A useful fluoroscopic test of the degree of the obstruction is to ask the
patient to cough In lesser degrees of the condition this act causes a jet of the
opaque cream to pass into the stomach
-R tnrooKAPxrrc Oovniot. or Treitwevt — I n the treatment of c&rdio
spasm (he first method to be tned is as a rule rejieated dilatation of the
spliincter by tlie merciin cesopbageal boucie This is best pas'ied in the first
instance under fluoro‘<copic control The mercury filled lower end of the
bougie is of course clearU Msible and if a mouthful of comparativeh dilute
(and so translucent) hanum cream be first giseu to outline the jwsition of the
sphincter the tij> of the bougie can lie manoiuvred down against the onfico of
tile sphincter and its passace through into the stomach obseiaed Tlie
tendency for the tulie to he honzontallv and push out tl e left fcsophageal wall
nm\ be counteracted b% makinir the patient licntl to the nglit or left The
latter posture i*! more hbely to be cfiectire
I slgl t tortuon t>
DISEASES OF THE PHARYNX AND (ESOPHAGUS 31
This method is successful m relieving to some extent the obstruction in
cases of moderate seventy It requires vrcekly repetition for some months,
and the degree of its success m any case is indicated b> the amount of the
relief of the patient’s symptoms anil the subsequent radiographic appeaiance
The lattei are at first thought disapiwmtmg Even altliough the sjmptoms
are largely abated, a considerable moiety of the msophageal dilatation reniams
and some food residue mil be held m the cesophagus If comparison mth the
radiograms taken before the treatment shows the cesophagectasia to be less
and the thieshold level of the residue to be lower the treatment maj be
regarded as satisfactorily controlling the condition
In the case of more drastic surgical treatment, such as forcible dilatation
of tlie spliuicter from below, or cardioplastj, the raibographic restitutio ad
xntegrum is more complete, as the sphmctcnc control has been largelj destroy ed
Spasm from C/Iceraf/on
'Xhc causative ulceration may be peptic, tuberculous, or sjphihtic All are
rare the two latter extremel 3 so A case of abscess of the oesophageal wall,
follow mg ulceration and causing ob'.troction, has been described
Peptic ulceration occurs in the lower part of the cesophagus, and is pro
sumed to result from regurgitation of acid chyme from tlie stomach The
sjmptoins are pam in the epigastrium and over the xiplustemum, precipitated
bj eating (especially drj foods) and iieartbitrn The pam waj last for half
an hour after food The spasm is intermittent, and concurrent w ith the pam
It may bo demonstrated radiologically by a barium cream after prehminarj e\
citation of the spasm by sw allowing imperfectly masticated dry biscuit or toast
Idiopathic Spasm
The wTiter has seen one ca'^e of spasm of the msophagus, about 4 inches
above the cardia in which no cause was detected either radiograpliicalh oi
bj means of the ocsophagoscope The obstruction was intermittent, and the
cesophagus above dilated as in cardiospasm The condition was kept satis
factorily under control bj the periodic passage of a meicur} liougie
(ESOPHAGEAL OBSTRUCTION FROM EXTRINSIC PRESSURE
A large number of extrinsic lesions maj cause cosopliagcal obstniction
Chief among them are
Aneurism of the thoracic aorta
Neoplasm of the mediastinum, lung, or neck ^
Enlarged mediastinal glands
Abscess or new grow tU of the spine
Retro sternal goitre
Tmction from fibrosed lung
32
ALIMENTARY IRACT
I>eft sided interlobar empjema
D>sphnp,ia Iu*iorm
In general «tuch sources of ctternal pressure cause obstruction of the
ccsopliagus onlj if tliej arc situated m the neck or upper thorax Tlieir
characteristics are de
scribed in the section
on the thorax
Gross pressure dis
phcenient of tho gullet
ma> t ike place in tho
lower thorax without
causing anv cesophageal
s\ mptoms
In obstruction from
such causes the
ns‘0}))ngxi5' j/iiUf d wjtJi
harmm will be seen to
bo displaced and its
lunitn reduced at the
site of pressure to a
cuned rat toil streak
widening out beloir to
a normal calibre
IDIOPATHIC ATONY
OP THE (ESOPHAGUS
This rare condition
has been described b\
ItosenhtMfi and
HolJ ntchl and Olbert
It consists of a fimc
tionnl atonj of tho
ccsophageal tube with-
out an> organic or
spastic obstruction
While Ihiids pass freclj down a thick hanuin paste pa^'ses \er\ slowlj and
with mild dysphagia
(ESOPHAGEAL DILATATION IN GASTRIC LESIONS
In certain gnstne lesions such as carcinoma of the fundus high hour gla'sS
contracture high partial gastrectomj and other lesions causing marked
diminution in tin capicitj of tho stomach reservoir dilatation of the
lower half of the a«ophagus max occur Tli% dilatation is similar to that of
DISEASES OF THE PHARYNX AND (ESOPHAGUS 33
ii minor degree of cardiospism, but the cardiac sphincter, instead of being
closed, IS ^^ldelJ patent (Fig 10)
(ESOPHAGEAL .VARIX
Tln*> condition, altjiough a comparative rant>, is now knomi to be less so
than pre\noU3ly supposed, as a result of the recognition of its radiographic
features The ^ aricose condition occurs in the lower part of the cesophagus
and IS caused b}' portal obstruction, m nhicli condition it forms one of the
channels of collateral circulation
Q’sophageal \an'c piesents a cliaractenstic appearance in a radiogram
taken to shon the mucosal pattern of the cesophagus A fairly liquid opaque
cream may be used, and the patient is best examined lying donn The
vanco«o mucosal folds arc then seen outlined uith barium A typical case
cannot be mistaken for anj’thing elac A colloidal baniim water suspension
IS the best medium to use, since tins tends to <leposit on the tortuous nigje
A Bucky grid should be used, to obtain the maximum contrast Prebminarj
Btropmisation maj help bj keeping the mucosa “dri , ’ and aiding tlie adliesion
of the contrast medium
THORACIC STOMACH
Complcto tliornuc stomach as n congenital nbnormabtj, with correspond
mgl5 short cesophagus is rare
Partial thoracic stomach is a less uncommon condition Both are described
in the section dealing with diaphragmatic hemia
RFFERCVCES
B\acL-\T, A E The Digestive Tract, lioniloii, 1930
B\P~ON\,T,Jnin ir<e/.r 1025 IV. 2500
IIoLzXNECirr, G mil Olbert D , Zetitrhr f JJm Med . lOio, LXXI, O]
llciUfT, A F , anil IlOvE, G Quart J Jted , 1929-30, XXlll, 491
Laxomead, r S Dm J Child Di» 1929. XXVI. 1.
Matiueu, A , and GOLU-MlTli, II L Amer d Surjr.lOSl XXII 233
pALroAAT, J , R<5nl(;c(»prfij'i« 1032, IV, 761
pAiEr-ON, R S , Dm J Dadiol . 1929 II. 331
I’AYSE. R T.Jinl J Surj, 1931, XIX, 142
I’tl All L X , JRril J Surg 1933, XX, 508
RosiMiFiM, T , / Kin Jfed , 1910, LXXI, 478
SciiiNZ, II R. Baev«cii, , and iriroL, E, ' Lehrhurh der Ront^cuiliagnoslik, '
Leipzi", 1932
\ n IT— 3
PART OyE
SECTION II
STOMACH, DUODENUJl AND DIAPHRAGJI
CHAPTER IV
GENERAL TECHNIQUE
The X RAV examination of the alimentary canal h m the mam bound up u ith
the use of contrast media The one in almost unuer«al use non is bannni
sulphate This has superseded the bismuth preparations— -the carbonate and
oxjclilondc — for tno reasons, the pharmacological effect of the latter and the
relative costs The hi&muth salts slow the rate of transit through the stomach
and duodenum and are constipating in the colon Their transit is about
tujee 08 slou as that of barium sulphate — a dmd\antage from the pomt of
Men of eximmation of the stomach and duodenum One advantage it
poroses over banum sulphate w its soothing power m gastro intestinal
lesions but birmm sulphate has tlu<i to a sbghter degree
Other contrast media uhtcli find occasional use are thorium salts and air
THE BARIUM EMULSION
Tile exact form of tlic \ chicle of the nicnJ is of no great consequence bo long
as it conforms to the following desiderata
(1) Consistency It muit lie fluid unifonn m the distnbution of the
contained barium, and of the viscosity of a thin cream For the examination
of the cpsophagus a thicker cream may Iks required
(2) If for use in the investigation of the stomach and duodenum it
siioiild contain no food The presence of (bod m the meal so delays the
opening of the pylorus as to make it difficult to study' the latter and the
diiotleniim satisfactorily
(1) Its taste and flavour must not lie unpleasant
(4) It must retain the barium salt m satisfictory susixinsion for a reason*
able length of time If properly proportioned it should maintain the su*pen
Sion for an hour or two at least
Vanous excipients hav e lieen nsed in the past The first m common use
was bread and milk a bad one bccau>e of its irregular texture Buttermilk,
arrow root, and other cereal prcjiarations have been mucb m vogue, and still are
GENERAL TECHNIQUE
35
largely used In the "wntcrs opinion they have the disadvantage, above
referred to, of being foods If tins is not objected to, they make admirable
media for the suspension “ Umbrose,” a proprietary article eontaiiung, in
addition to bamim sulphate, dned milk, arrowroot, sugar, and chocolate, is
widely used HorUck’s Shadow food is anotlicr very satisfacton food con-
taining preparation, and may be used with advantage as the first or “ motor ”
meal m the double meal technique {tide tn/ra) Scett contnbuted a definite
advance in technique when he deviscil the food free barium emulsion, novv so
w idcly used
The follouing are the formula? winch the writer uses
Barium
Bunum Sulphate
S«eeljsnne
R&spberrj EsAcnee
Gum Tragacanth
Aq ad
liAmvst Fnzma
Oanmn SoJphala
o 10
Cum Tra^a^anth
grs 40
Aflua Cbloroformi
S s
A(] ad
e 1
CoUoidal Danum Sulphate
S 10
Aq ad
1
For ordinary oesophageal examinations the above meal formula is satis-
factory In special cases its consistency may be stiffened by atbmxturo of
bnnum sulphate in powder form Tlie bamun sulphate must be in the finest
subdivnsion possible It is now available m colloidal precipitation, and when
in such form requires no trngacantb to suspend it, so fine are its particles
The degree of subdivision of any specimen of banum may easily be oliserved
under the microscope The particles should be fairly uniform m size In
equality in the size wall render it difficult to maintain the emuNion for long
The average size of the particles can be graded microscopically against a
colloidal specimen
TAvp i\o*xw.w AWAdsJAvj .vs Jvasf xuaile .w? j>.v eiffrtsjsr .wavew Hand .wj si.vt.b
a mortar and pestle is a laborious process, anti much less efficient
All the ingredients except the gum tragacanth should be stenliaed, ns
should the container in w Inch it is muted, and the bottles m which it is stored
lliis applies particularly to the banum meal emuNion Decomposition of this
emulsion tcnils to occur on keeping it for long with the formation of traces of
sulphides This phenomenon is> instantly delectable hy the smell on uncorking
the bottle It may result from decomposition of the tragacanth, or from
growth of mould on the surface of the liquid Such an occurrence is sati-s
factorily prev ented hy the addition of chloroform w atcr, in the case of the
banum enema, but the ta<>to of this ingredient is objected to bv mnnv natients
3 10
grv 2
q 45
jrrs 60
6 1
30
•VLlMEVrAB\ TRxVCrr
and it IS l)cst omitted from a nicaf emtihion Ifence the necessity forstenlismg
as man\ of the ingredients ns possible and the tise of fresh emuKions onl\
Boiling the tragncanth destro\s Us emal&ifj mg properties Benzoic acid added
to tlie amount of 25 o|)er cent .isancJTicient preservative, but some patients
object to Its taste also and complain of slight stinging or smarting in the
throat after swallowing a meal contaming-it
TECHNIQUE OF THE BARIUM MEAL EXAMINATION
This IS both fluoroscopic and radiographic Both are of importance the
latter the more so It cannot be too stroiigK emphasised that the es. ence of a
satisfactory X rav investigation of the stomach and duodennm lies m the taking
of an adequate senes of radiograms Isot even the most prolonged and
searching fluoroscopy should lie ttccepterl as a sulwtitiite for this The two
methods arc complementary and while neither should be dispensed wath in
tnonv eases a senes of radiograms provides all the infonnation necessary The
use of fluoroscopv alone liowover involves senous nsk of on organic lesion
remaining undetectevl
llie mimlxir of minor v ariations m banum meal technique is legion and an
attempt to indicate them all would fulfil no n«cfiil purpose
\ complete teclmiquo should include ndiographic study of both the com
pleteh filled lumen of the stomach and duodenum and also the relief pattern
f f the mut•o^a The latter as-jumes a relatively greater importante in certain
cases such oi chronic gastritis and the stomach after operation particularlv
w hen spbincteric control has been aWhshed Normallv the sludv of the com
plctcU filled viseus is of greater importance but neither should be omitted
Time Intervals in Barium meal Examination
1 here are certain tune intervals after the mgostion of a haniim meal whitli
are radio^^raphicallv important alTonling ns thev do the best opportunity for
invc'itigiting successive portions of the olimcntarv tract Thev form the bssis
of a rcnitine technique ami are subject to variations to meet special cases
(1) Immediatfuv Arrui — The first fifteen minutes after taking the meal
Is the vital porioil for the investigation of the fitomacli and dtioilenum It is
rfrffWfg’ thK enten ttl ttatC thir mixjontf of pepfa? crAarrs err citremamafa an?
demonstrated and it is imjiortant to take a seneo of radiograms at this stage
The stomach and duodenum should first lie studied fluorosoopically and
rndiographicallv after one nioutlifiil of the medium to demonstrate the muco«al
pittem Immeihately following this the filled viscus should lie exammed
(2) 0\L Hocu After —Examination at this stage serves to determine the
jircHiicc of early gastric evacuation of a Inriiim * rest in an ulcer crater
ofdiio<ltnal and upper jejunal ob-tniefion ami of the gastric mucosal pattern
if this has not already been complttelv studied at the lieginning of the meal
GEXERAL TECHXIQUE
37
(3) Si\ Hours After — ^Tlus is »n importaut stage It slions anj patJio
logical stasis in the stomach It is now generally accepted that delay in
cmptjnng of a lesser degree timn six houi% has v ith some exceptions, little or no
significance, while nn> considerable six hour gastric residue is usuallj of
pathological import
At this stage also the terminal ilenm, apjiendix, ciecum and right colon
ma\ be studied The supine position is the most comement for this purpose
(4) Twexit, four Hours After — ^T he appendix maj be better demon
strated at this time than at six hours and the colon to a degree virj uig accord'
ing to the distribution therem
(5) At Foptx ETOiiT Hours After and at succeccbng daily intervals,
depending on the rate of colonic emptying
ith the above desiderata m mmd, the routine of a barium meal examina-
tion must be planned according to the time that can be de\ oted to it
The routine of choice is to give a sivyh meal and to follow jt in a straight
forward manner through the above stages In hospital practice, if the ludio
legist IS able to paj a \asit of a few hours onlv m the afternoon it may be
impossible for him to examine the patient personally at everj stage witli a
single meal technique and a compromise is sometimes adopted in the form of
the double meal technique acsociatcd with the name of Handel, In tins the
patient takes at home the first or motor, barium meal, usuallj of the cereal
type, until a content of 6 oz ol banum sulphate He attends the X raj
department six hours later For example if the motor meal be taken at 8
am, the first attendance would be at 2 pra bj which time the contrast
medium will norraallj occupj the terminal ileum, caicum and right colon
After the^e portions of the tract have been esnroined anti the presence or
alwnce of gastric stasis noted, another meal is given and the stomach and
duodenum investigated Hie patient is seen again an hour later, and on the
following day if neoessarj
The method h<as tlie disadvantage that the first meal in the transverse colon
niaj ob«curo the pjlonc and duodenal regioits to some extent
FHSUMStiARy PRSPARATSOR
Aperients — ^TIus is a matter on which conflicting views obtain Some
radiologists order an aperient a'» a routine on the day before the examination,
whilst others allow one to be taken if it is the patients daily habit The
. w nter is opposed to both thej>e course*!, on the grounds that an aperient taken
the dnj before is apt to disturb the normal (or pathological) transit of the meal
through the alimcntarj canal A safer plan is to av old all aperients if possible,
and if the patient s colonic habit makes some relief neces«arv , to give an apen
cut two dajs before, and an enema on the evening before the examination
An exception to this rule is when thi appendix i» suspect An aperient tends
to eniptj the appendix, and so ensure its suWquent filbng with barium
38
ALTNIEOTARY TRACT
Irt such cases an apcnent slioiiW be given as a routine on the clay before
the examination
Drugs — All medicaments contauimg bismuth, phosphorus, calcium, or
other drugs of n high atoimc u eight should be u ithheld during the examination,
and for a dav or tuo before "Magncsittm carbonate ami Bodium hicirbonato
niaj be talvcn as required
Food — In the single meal technique the ideal is to « ithliold all food on the
morning of the examination, if the first examination la to tahe place saj, at
10 a m This is imperatix e if the patient bo suffering from pyloric obstruction
or stenosis In some cases, houe^er, this rule maj he relaxed and the patient
allowed a cup of tea and a small piece of dry toast tiro hours before the e^ram
Illation Although this is a relaxation appreciated b> the patient, it should he
permitted onlj u hen the state of the stomach and duodenum is not in question
Hetwcen the first sitting and that one hour later, no food or liquid should be
tiken If a restorati\c such as brand) or sal volatile, is really necessary
heenusc of the patient's general condition it should not be intbhcld
Between the one and six hour examinations it is the practice of many
again to allow no food but this is m most cases an unnecessary deprivation,
and unlc^s there is present a gross gastric stasis a light lunch of fish or eggs is
];)onnissiblo without detriment to the investigation Subsequent to this there
are no radiological imhcations for dietetic restnctions
The prchminarj preparation for the double meal technique is similar, with
the following sanations (1) In lieu of breakfast on the morning of the
examination the cereal barium meal is taken This contains food ami so
huatains the patient (2) Xo food or liquid is allowed between this and the
first examination hours later
In the later stages, when the colon is being studied, no aperient should
he allowed
In cases of »»e\ere colonic stasis however, this rule cannot be applied for
too long With each succeeding daj, if no action of the bowels takes place,
there 13 an increasing inspissation of the barium, with foniiation of scjbaU
and if a pirtial organic ohbtruction be present in the left half of tho colon a
w'nous exacerbation luaj result from neglect of this point.
CHAITCR \
THE KORAIAL STO'MACH
ANATOMY
Thf STOiiACn 13 uswiUj desicnbed in fliree portions tlio fundus or pirs
eartlmca bod;y or pars media and pjlonc antrum or pars pvlonca
The fundus lies above the level of the cartliic orifice or cardia the pjlonc
antrum is the portion Ijnng between the mcisura angulans and the pylonc
canal or pylorus and the bo<lj is repre«ente<I by the intervening portion
(Fig 20)
Form of the Stomach — This is ven variable depending cluefly on the
habitua of tiie patient It is usual to describe three types of stomach, hvper
tome orthotonio and hapotonic corresponding to the three tj pea of habitus
the Jivpcr ortho and hypostheiiic Tlie iiornnl stomach may show an
infinite senes of gradations between these limits and the entenon as to its
normality m this respect is that H should conform to the general habitus
The three types of stomacli are coramonh likened to a steerhom or cowhom
a J and a fish hook respectively
Anatomical Relationships of the Stomach — Certain relationslups are of
radiographic importance The fundus is in relationship above and belund
with the diaphragm and in front vntJj the under surface of the hver
Tlie nntenor surface is m contact with the anterior abdominal wall The
posterior surface hos against the stomach bed composed of from above
downwards the diaphragm spleen pancreas and duodeno jejunal flexure
To tlie left arc tlie splenic flexure and the adjacent Umbs of transverse and
descending portions of tiie colon
T!id atomach lied was prc\ loush held to be m posterior apposition to
the whole of the stomach Karfiofogy has shown that the lower half of the
stomach lies below those limits The pancreas forms a transverse ndge w Inch
shghtlv indents tlie stomach near its middle so that m a lateral view the upjier
half of tlie stomach IS inclined downwards and forwards whilst the lower half is
perpendicularly thsposed An exception to this is the hypertonic tvpe in whicli
most of the stomacli is apposed to the stomach bed This pancreatic ndge is
responsible for the posterior (pancreatic) mcisura of Ttnmny desenbed later
TECHNIQUE OF EXAMINATION OF THE STOMACH
The examination should lie commenced with the patient in the erect
jX)«ition in the screening «tantl The patient is instructed to swallow a
39
40
ALIMEXTARY TRACT
jnontljful of the bnnum crenm, and this is observed ui its jn-ssage into the
stomich ^^Ith the right gloved hand this bolus is pushed into each part of
the stomach in an attempt to “vvhitenash” the mucosa In this uaj the
mucosal pattern maj be observetl fluoroscopicallj , and an abnormahtj therein,
detected After recording this radiographicallyin the supine or prone pasition,
if the vieu m the erect position faiK to show the pattern in the upper portion of
the stomach satisfactorily the stomacli ls then filled, its filling being Matched
the uhile As the capacity of the stomach vanes, the amount of the barium
cream necessary to MMialise its lumen will also vary An average amount
IS 10-12 oz
A\hen the stomach is filled, certain further points must be determine<l
fluoroscopieally , and should he noted as a routine Tliej arc the position of
the stomach its tone and peristalsis the flexibility of the gastric wall, and the
pre'>ence of any persistent irregularity of its contours The patient is then
rotated into both oblique positions to bnng into view the anterior and iiostcnor
walls of the stomach and at times a true lateral po'ition may lie necessary to
show a pobtcnop wall ulcer m profile The pylorus may not be filled at first,
but if not firm palpation wnth the gloved hand will serve to push some of the
cream through it into the dtiodemim Certam points should be noted m this
iinportaut procedure
It should he carried out with the tips of the four fingers of the right hand,
hv a progrc’*si\e massaging movement upwards and to the patient’s right In
tlie hyqHitonio stomach the pressure will be more eonvemently excrteil by the
ulnar border of the hand and m an upward direction
The pre^ure should coincide with a peristaltic wave , that is to say, when
a wave Ins progressed about halfway down the paru pylonca, and the pre-
pyloric portion contains a roimdedmassofhanum Imm^iately aftertJu-sthe
pylorus tends to open of itself and htfle or no pressure may lie required to fill
the pvJonr cinal and duodenal bulb
If the stomach is very hypertonic the pylorus and bulb may be hidden
behind the supenmpo-ed shadow of the pylonc antrum Rotation of the
patient into the first or nght obhque position {and, often, mto the left oblique)
will then bring these structures into view Again, if the stomach be hypotonic
and of the fish hook tyjie the second portion of the duodenum may be directly
bilund the py lone t anal in the true postero antenor view, and a similar rotation
of the patient be netessary to separate their supenmposeil outhness
Frequently the resting stomach contains an ounce or two of secretion and
the liarmm meal when taken is opt to float part of this up into the pylone
antrum where it is held trapjied, as in the distal limb of a U tulKi buch a
state of a/fairs is evident as a horizontal banum level in the pylonc nntrum
Before the pvlonis and duoilenal bulb can be vn:,uali«ed, thw trappeil resting
yuice must l>e forced through mto the duodenum, a process vrluch may require
f^vcml palpatory niampulafions each coinciding with a peristaltic wave If
THE NORAIAL STO’\L\CH
41
the pj loriis be normal not more thin half a doten such manipulations ire as a
rule nccessarj
During the fluoroscopj the relitionslup of any tender pressure points to the
« gistric ind duodenal shadou sliould be noted and also the relationslup of anj
tumour mQ«!S palpable clmically As it is frequently difficult to feel such a
mass Mith tlie eximming hind encased in a thick lead rubber glo\ e it mnj be
necessary to mark the site of the mass b} a ring of thm mre fixed to the nb
dommal u all w ith adhesi\ e strapping It is best to m\ estigate tlus point with
the patient supine and quite impemtivo that both procedures the delineation
of the tumour bv the uire ring and the ndioscopic palpation should be per
formed without moving the petition of the patient
After the fluoroscopic oximination his been completed it remains to take
a fcenea of radiograms Tliese are of prime importance becau'ie of the difficult)
of detecting fine changes radioscopicallj and as one important proof of the
organic nature of an abnonnal ajipeirance is in its constancy thit con-stanc)
must be demonstnted in sevcril radiograms Tins is particuhrl) applicable
to the pjlorus and duodenum
The precise position of the lesion susiiected will determine the position m
whicli the ndiogram is taken — eg for the fundus the supine position is the
most smtiblo— but as a routine at least two radiognms of the whole stomach
and duodenum should be taken and at least four of the pyJoro duodenal area
Some form of sonal ippantus is desirable for these last The Bechre sernl
apparatus and the Bag apparatus ate admirable but require dual control A
convenient and simple form is that devised bj Biddell In the writer s modi
ficationof this there is au aperture 0x5 inches m the centre of n lead backed
frame so arranged that the four quarters of a 12 x 10 inch film cm be brought
successiiely in front of the aj[)erture and exposed Four C x 5 inch radio
grams of a suspected area are thus com erueiitU arranged on one film and cm
reidily be compired one ivith the other Tlic ibsid\nntioe of tlus apparatus
is that it IS blind i e some fen seconds must elapse between screening and
the taking of the first picture The Berg and BecUre types of apparatus on
tlieotfier hand make it possible to ridiograph a susjiectcdarei within a second
of seeing it fUioroscopicaUj and so enable one to choo«e the most sitisfactorj
pliase in a penst altic C) clc for the purpose of its demonstration
Compression — f^ome form of compression is frequent!) required intli the
patient erect to demonstrate such points as the upper portion of a stomach
w hich IS h) pi tome and m w Inch the banuni has sagged into a dependent pool
to ensure complete fi!hn„ of the duotlenal bulb etc Tlie most useful for this
purpose arc a senes of lambs wxiol pads of ^arloU3 thicknesses and sizes An
obvious corolim of this is that the Rcreeu and cassette holder of the upright
stand should bo suflicient!) ngitl to exert firm pressure
Berg has drawn attention to the necessity for w hat he cilia graduited com
pre Sion and aimed ex|H)surcs in the radiographic demonstration of duodenal
42
ALniENTARl IRACl
ulcer }Ie points out tlmt a radiogram taken uitliout compression maj
entirelj fail to demonstrate a duodenal ulcer on the anterior or posterior nail
of the duodenal bulb — c« face m other wortls — nbile suitably applied com
presMon maa emptj the duodenal bulb sulEciently to bring it into relief He
lias dc\ i«cd for tlus purpose n special scnal compression apparatus for nse u itli
an upright screening stand — the so called Ikrg explorator Tlus is undoubtedlj
the most sati«factorj tjite of apparatus of this nature at the time of ^vnting
A Pimple snb-)titute is a pjramidal lamtn wool pad This is \erj effectne
when carefullj applied It is best made up of four square jiads of lambs wool
e uh m a calico coier and sewn tc^etlier wath tapes in the form of a step
pyramid Ihe largest pad at the base of the pj ramul is conveiuentlj bad ed
with three pU wood and the whole arrangement of pads enclosed m a
pjTamidal calico casing
Tlie Chaoul compre%SiOn band in which pressine is everted by the inflation
of a bemispbtucal rubber band btrapiied bj webbing to the abdomen is
diflicult in practice to apph aecuratolj
THE MUCOSAL RELIEF PATTERN OF THE STOMACH
It IS onh rcccntl} that much attention has been paid to tlus aspect of
gastne and duodenal \ ra\ cvammation particular)} as a result of the work of
dorsseU Herg andCfaotd
Technique — Frequentlj the mucosal pattern can be demonstrated with the
stniulartl barium cream either after a fen mouthfuls ha\c been taken or at
the end of an hour when the stomach is neirlj emptj Excess of mucus or
«ecretion nia\ present this as will too thick a meal In doubtful cases there
fore in wlucli a relief picture is of importance steps must be taken to ensure
that the ptomach is quite empt\ nndna])ecial contrast medium used The
examination is 1 est conducted early m tho morning with the patient fasting
o\ ernipht \ thin colloidal baniim cream w ith no tragacanth maj be effcctiye
or a thorium oxide suspension sucli as diagiiothonne Tlus is a colloidal
Rusjwnsion which is supposed to flocculate on reaching the mucosa and so to
produce \ thm coating o\ cr its surface About i to I oz of either of the above
ni'-dia IS sufhcient and should be taken l}ang down Too much obscures
the pattern The patient then lies on each side and then prone to coat the
wiiolc mueesa
‘screen examination will show the best position for a radiogram usuall}
prone
In the stuch of the mucosal pattern the following points must bo noticed
( 1 ) Complete absence of the rugre as in atrophic gastritis or hnitis plastica
(2) Locatiscil absence as in carcinoma
(3) Interruption and jiuckenng from ulcer
(4) Increase m sire of the ruga' and increased tortuositj both met with m
hypertrophic gastritis
THE XORAUL STOMACH
43
(0) Abnormal persistent fieebs or bnnum rests m an ulcer crater or
carcinomatous cresice
AIR INSUFFLATION OF THE STOMACH
Dtaal and Bechre base developed a technique for investigating the
stoniacli after disten'sjon with gas In their method an Emhom tube is
swallovvcd bj the patient The stomach must be quite emptj, and anj fluid
residue should first bo drawn off through the Einhorn tube The stomach is
then slowly inflated under fluoroscopic control Care must be taken to avoid
undue distension The inflation apparatus maj with advantage include a
pressure gauge and if the patient eiperiences anj pam during the inflation,
the admmi'stration must be stopped and a little air released from the stomach
This method is of greatest value when combined with a whitewash
method — the cotiche tntnee of the»e authors The thin coating of barium or
of tlionum on the mucosa throws it into greater relief when there is the added
contrast of the air distension Erect, prone, supine, lateral, horizontal and
'[Vendelcnburg positions maj all be necessary m different cases, depending on
the site of the lesion to be studied A tilting table i:> of great convenience in
tlus technique
The “ blind ' method of insufllation, by SeiiUitz or similar powders, is
unsatisfactory, since tiic degree cannot be controlled, and fluid is introduced
nt the vame time
Tlie^e authors state that valuable information may be obtained regarding
Evcxpiialoid CiBCiNOMA — ^In tins condition the moss may be seen pro
trudmg into the air filled lumen and the site of origin of the growth may be
determined
Gastric PoLin — According to those author*, the number and disposition
of the poljqii can bo detcrroiDcd, and pedunculation made out
In Prrnc Ulcer tlus procedure is contraindicated, for fear of perforation
Pancreatic Tcjioctrs — A htcral radiogram, taken with patient lying
prone, may show the tumour mass projecting into the gas filled stomach
File inec’dott’ is as yet rcibAvtay onAieu’, ami’itr I'llir imcjumy KTi^e'O-Vircttir
improbable that it offers advantages over the more established methods
commensurate with the risks of perforvtioii and tlie unpleasantness of swallow*
mg the Emhom tube In certain cases of exceptional tUfficulty or obscurity
It may, however, be a diagnostic measure of considerable value
The most convenient time to conduct the pneumogastric examination is in
the evening, six to eight hours after the ordinary baniim meal The patient
should fast during that dav.
NORMAL APPEARANCE OF THE STOMACH IN THE ERECT POSITION
Before the meal is gi\ en the gastnc fundus only is v iMble, outlined by gas
Tlus gas bubble, »<> if t)
44
ALn^F^^ARl TRACT
Rtomacli 13 cnipt\ If there is im considerable iroouiif of resting juice in the
«tonnc!i the gas bubble ninj be limited below by n horizontal fluid lei el
hen the opique trenin is hwiUowed it is held up for a feiv eecouds on
j»nsMng into the stomach just beloii the cardiac onfice ami graduallv slides
down tlte lefi,ser curie to the lower jiole In an empt\ stomach of good tone
t! L barium docs not form a pool at the lower pole but canalises the stomach
as more of the meal is taken until graduallv the whole gastric lumen is dis
tended and filled w ith tlie opirpie medium with the eveeption of the gas filled
fundiiR The upper le\ el of the barium emulsion forms with the gas aboa e it
a lionzontnl level and anj secretion alreadi pre«ent
in the stomach forms a superficial fluid lajer between
the two
Cardiac Orifice — In most caRcs m the erect jio'ntion
tins onfice is alxive the le\el of the banum but if the
gas bubble be aery small or absent it will l»e visible
as a puckered projection of the banum shadow
Immediately below it there is sometimes a projection
to the left of the lesser curve which ma\ simulate
an uJc-er niche Indeed it maj be impossible to cbffer
entiate radiograpliicnllv between them The cardiac
orifice IS liowevcr best de^lon^t^1ted in the supine
position
The Lesser Curve presents withtheal)o\ee\ception
a smooth regular contour down to the incisurn
nngulans where it turns upwards on it«elf the acute
iiesh (f this Hunt angulation dcpeudnio on the t\-j)o of stomach From the
incisiim angulnris to the p\lonis the leaser cunc is similarlj regular but
‘•ometnuea jirescnts a small notch about i— J inch in dejith a little short of the
pjlonc canil Tins is due to a mucosa! fold and is not pathological
irregulanta of the lesser curve cithern protrusion or a defect should be
regarded ns representing an organic lesion until it is proved to be the reverse
The Greater Curve, on the other hand is more variable in its contour
Norranllv Miioolh and iiiulnlnted b\ jicnstnlsis it maj present a notched
apiwannce from peverai causes oncofwhicii not being patliological concerns
Us here Tf the roJou jua the xi^jitui xd" Iheiplenje flevwe dee/Jv h-austrated
and be Ij mg closelj nppo ed to the greater cun e of the stomach it mav pro
dtiec a senes of indentations m the latter correspondmo to the haustral bulges
m the colon This tvpe of indentation has to lie distinguished from tho«c
eaU'Pd b\ increased rugositv ofthegastnc mucosa andgiistrcjspasm resjwctivelv
The Lower Tole is hiHi m jKisition and of mild conv cxitj m the hj'pertomc
stomach and low and parabolic m outhne in tbc li>7>otonic In verv hvjio
tome stomachs its contour becomea bulbous the Innum tending to form a jxiol
m it Tins degree is probablv over tho borderline of the norms! The himts
Fir 0— 'sullwsons
of 11 rule rael (a) T ii
1 w fprniT or j RMPBrd
a (1 J Uoilv coq u < r
I ars roetiui (r) 1 vloric
nninun or par<t p)l n a
THE \0R-\L4L SIO’^LACH
45
of the normal level of the lott er pole are a matter of dispute The intercristil
line (the motlern equivalent of the old halfpennv on the umbihcu's) was formerlv
gi\en as the louer normal limit but it is now recognised that lower IcNels are
conipitible with normal
health Prohablv a point
halfwaj between the inter
cnstal and pubic levels marks
the nonnal lower hmit
The Pylorus, when seen
in profile is a short regulir
canal about { inch in length
Its contours are jierfcctly
smooth and join the lesser
and greater curves in blunt
right angles Its calibre
as seen m a radiogram
ilepcnds on the degree of
relaxition of the pjlonc
sphincter and Nnnea from
nil up to o 0 mm The
pyloro duodcinl junction is
also nornnilj ven regular
often geometrically so and
can be compared with the
junction of the stem md
body of a musiiroom
The threctioii of the long
axis of the ji\Ioric canal
dejiends on the tyqie of
«tonnch In the hsjiertonic
t jqie it IS directed backw ards
to tho right and shghth up
wards In the orthotomc it fio l —Normal onloto up stonaci
i', upwattls <5lightly to the
right and slightly backinrds w hile m the hj-potonic ts jic it is either directed
iipw arils or upw srds and sbghth to the left
The jiosition of the pylorus m the abdomen also \*anc'5 with the tspe of
stomach The lesser the tone the lower its Iciel is \ornnliy it \ane«
between a point niidwav between the Niphistcmum and umbilicus and the
iimbihcus itself It is held by some authorities that it descends to a lower
!e^el only in ci«ca of gastroptosis
Tone of the Stomach — Ajiart from pathological lanations the gastric tone
follows the habitus of the indi\idual lieiog greatest in the Inpersthenic
46
AT.I'MEKTAUY TIIACT
indjvjdiial, and lca<Jt jn the hjpo^thciuc Its estimation is simple ^^]len the
stomach is fillet! with barium emulsion, bj comparison of the relative aaidths
of the upper and lower parts of the gastnc lumen, and the general conformation
of the stomach
In hj-pertonus the stomach is ** stcerliom ” in shape, its lumen largest
ahoao, and tapering to the pjloma Tlie incisura angularui is feebly repre
sented, and the greater cun, e descends onlj a small distance below the pj lone
level Indeed /n markwl liypertonirs the pjlonis ma> bo the Joweit |>oint of
the Btomnch (Fig 22)
Inorthotonusthestomach
13 J shaped, the incisura
angidans is fairlj well
marked, and the lower pole of
the stomach about etiinl m
calibre to the upper portion
of the pars media The most
dependent portion of the
stomach lies about the mtor*
cnstal lea el
In the hypotonic stomach
Its form IS fish hook Ihc
greater curve at the lower pole tends to sag down, making the lumen there
larger than elsew here The lumen of the pars media collapses from incomplete
filling and dragging The most dependent portion of the greater curve maj
reach half uaj between the umbilicus and sjmpb}sis pubis
Apart from habitus there are \arious other factors which modifa gastnc
tone Vagal stimulation increases it and sympathetic stimulation does the
rcaerse IVjchic factors maj Imae a marked temporary effect Fear and
depression diminish tone ns docs nausea from an unpleasant taste — c g of a
badlj flaa (Hired banum meal ' Converselj it increases during excitement
The effect of gastric hiliarj and diwlenal lesions la varmble but as a rule
the first depresses it If a gall bladder lesion has an} effect, it is usinll}
deiircshuig while a duodenal lesion ma^ do either
Peristalsis — Tlie peristaltic waaes in the stomach begin high up in the
pars media where the} are aerj shallow As the} aprend downwards they
ftecomc (fwper hxtt tftrs (I’ecpening w citreffw on tho gruafer cone trnfrf the
incisura angulnris is reached Alxne that point the peristaltic unduhtions of
the les-mrcuraenre atra small B} the time it has passed the incisura nngularis
the wave has become deep, and aliout midwi} between that point and the
palonis complotelv obliterates the gastnc lumen trapping a iiortion of the
gastnc contents m front of it If the pylonis has not opened, a rcflu’c takes
place past the peristaltic nng hut after a few such abortive wascs the j)}lonis
oiiens, and a mass of banum is expelled into the duodenal bulb, which it fills
THE XORilAL STO'VLACH
47
Succe^i\o waves form behind each other at ‘'iicJrrate thit two or tliree are
\ isible m the stomach at anv instant
It IS held by tome that the initial \ra\e occurring after a resting plnse
\shen food is taken commences at the level of the mcisura angulans , that is
at the lo^\e^ pole vhere the first distension of the gastnc wall b’v food takes
plice The imter has
not been able to satitjf\
hint‘?e}F that this is the
case
Apart from ob
structive atonj of the
stomach the gastnc
peristalsis is related to
its tone being most
marked in hj^iertonus
and least in Inpo
tonu'? In the e\cep
tion mentioned nbove
the stimulus of food
nstmllr induces a short
bout of ^ volcnt lij-per
peristalsis followed In
complete cessation
Hyperpenstaisis is
not a phj siologieil
condition It raaj be
duo to a number of
ciiLses and is of two
types obstructive and
non obstructive Tlic
former occurs in
piienc snii duodenal
obstniction (q t )
Non ob8t^uctl^e
hj pcrpcristalsis is
mo^t commonij due 3 ~G»- mcl.. i«lu.
to duodenal iiUeration but maj result from a biharj or appendicular lesion
and in aehlorhvdna It ehows m a radiogrtm by a laigcr number of waves
smaller tlian the nomnl Tnsteadoftuoortlireewa\es thereniaj beasmanv
as siv or scien present at the same tune Tlie length of eich naie i^ smaller
and the rate of progression faster (Fig 23J
The “ Antral Sphincter —After much conflict of opinion the existence or
not of this spliincter, which has forjenra lieen dcscrib^ bi phj «io?ogists bas
ALTMEXTARY TRACT
4S
lieen dcculetl m the negitivc, chieflj as a result of the cinematographic \\ork
of Fftrs^eU and Kacslle The appearance of the sphincter is due merely to the
decjicning of the pjloric waves in the pjlonc antrum As one sweeps on
townnls the pjlonis, another forms behind It, and the progre^ire nature
of tliC'O contractions rules out the theory that there is anj true splunctenc
action
Cascade Stomach {syn “ cup and spiH ” physiological hourglass,
estoniac cn coupe a champagne) — This curious npjiearance is one of
Joculation and marked dilatation of the fundus T.lie contrast medium
passes tliitmgh the cardia into the
fiindal loruhis, the lower part of
winch it fills It then siulls do\ni
into the lower part of the stomach,
a seim-elliptical pool remninmg
above Balloomng of the fundus
IS a common feature in these cases
(Figs 24 and 25)
The lateral view shows the
loculation to bo duo to the posterior
wall of the stomach forming a shelf,
which traps the meal m a shallow
trough When this is filled to the
brnn tlie hanum spill> over in
front and fills the lower storaich
At times the lower portion of the
Rtonnch is rotated and displaced
to the nght, and drawni upwards
In other ca«cs only tlie upward
displacement exists
Several causes are a>signed to
this condition
(I) Distension oftiie Splenic
FuemteI:. WTrn Gas — ^This, causing
pressure on the jHi^tenor w all of the stomach just below the lev el of the cardiac
orifice certainly accounts for n certain numlicr of cases Dispersal of the gas
iCMiits in the stomach assuming its normal position and contour
(2) Lor vLisFD MrvcctdVn HvptRTONts, with associated fundal ballooning,
pirticularlv of a bind of oblique fibres in the lower pastenor part of the
tundus Tlie cau‘«c of this is unknown
(3) LoniisFD ‘5r\s3i and
(4) CoNTiivtTiON op PrniGASTRic APHfcsioNs may produce a similar
opjiearance hut, as iwithological leMons, should be excluded from the classi-
fication of “ cascade stomach ’
tic- — Vhl 1 dpjTTw of cii.-<R<li stnmarli
THE ^ORMAL B'^oMACn
40
Not lufref^uentlj the casc'ide effect is gross as to produce a complete
hour glass appearance In cases of this dejjree the splcme fleviiro is usualh
coiled in tlie left cupola Another cunous effect tint is occasionally produced
IS a hlunt projection high up on the
lesser cunc It muat not be nils
taken for an ulcer a
NORMAL APPEARANCES IN THE
SUPINE POSITION
ith the subject in this poaition
the spine and stnictures in front of
it act ns a watershed separating the
conitent^ oi'" itlc stbmncil in t\\o
unequal portions asmill pjloncand
a large fundal Most of the opaque
meal falls back into the fundus and
tins jiosition 13 the most satisfactorj
for the demonstration of that
jiortion The contour of the fundui
juaj be quite regular and smooth or
maj show a senes of indentations
regulnc m character from mucosal
folds The presence or absence of
these mucosal notches depends on
the degree of the gastric tone at the
moment and the amount of Us con
tents (Fig 2G)
The pars tncdia is as a rule
incompletely filled An\ gas present
tends to collect m this the highest
part of the stomach in the supine
position As a rule the rug-e are
Msible from a coating of barium
Xhe stomacli lias a higher and more
tmnsa erso disposition in tins xio'-ition
than in the erect The duodenum is
likewise higher This jwstural dis
placement upivanls ^-ane^ in degree
from 1 to 4 inches or more depending largely on the tonic type It is greater
111 the h\iK)lomo
Ihe p\ lone antrum usually coiitaina a sraajj amount of the opaque mcdnim,
ui a mas-, sepimto from the fundal pool If, however, gastric tone be marked,
\-R II — t
“a — MfiTVfHi cascade stomach postcro
antcr or and lateral ^ lews
50
ALIMENTARY TRACT
and if no gis be prc'cnt the two shadows may be joined bj the banum filling
np the par? media
If tliere 13 a sufficiencj of banum m the p\lonc antrum the pjlonc canal
and duodenal bulb mnj be well Msualised as a rule however they are 1 otter
seen m the erect or prone postures Tlie aupine frequentlj fails to provide a
column or head of banum cream sufficient to promote complete filhng of
the duodena] cap
F TI Tu'xntng in a personal communication has drawn attention to an
anatomical vanation which he calls the posterior (pancreatic) incisura He
tic 0 ‘Normal iitomarl ap|x«ronce m the r p no | os t on
ascertained bj fitudyin^ tl c stomacli|in lateral films in the supine jiosition
that the pancreatic ndge often causes an infolding of the gastnc wall If this
infol ling reaches the surface of the Imrium (m the supine position) an incisura
is fonned which maj either crov» the stomach oronli reach half was across it
Behind this infolding of the gastnc wall a triangular filling defect is present
rej re enting the bodj of the pancreas il'^elf (tide section on pancreas) The
mfildmg thercfire simulates a true spastic incisura m the supine j)o tero
anterior sicw from which it raaa be distinguished hj two features (fl) it is
crossed h? muco‘«il folds {b) it disappears m the prone iv>«ition occurs
11 ualh in ptotic women
THE NORaUL STOJIACH
61
NORMAL APPEARANCES IN THE PRONE POSITION
In this position tiie gravity relationships are reversed The fundus is
much the higliest, the pars media and pylonc antrum m front of the spmal
column the most dependent, and the pylorus and duodenum intermediate,
aiost of the opaquo medium \viH there
fore tend to gravitate to the pars media
and pylonc antrum, and gas m the stomach
to rise to the fundus and pylorus All the
gas can be collected in the fundus by askmg
the subject first to he on the right side before
turning into the prone position
Tlie fundus uiU therefore be incompletely
outlined The mucosal pattern of the fundus,
howeier, fiequently stands out nell (Fig 27)
The pars media and pylonc antrum are nell
outhned, and penstalsts m them is usually
more active than in the erect position Tlie
pylonc canal and duodenum nearly aluajs
fill satisfactonly In this mcu quite uell-
marked penstaltic uaies are seen on the
lessor cune Indeed, in the very hypotomc
types of stomach this may be the only
position in uhicli to see these two stnictures
properly outlined If, as occasionally
Jiappcns. the pylonc antrum overlies the
pylonc canal, slight rotation of the subject
will separate tlie two sliadous The mucosal
patlem of the para media ii easily demon- tJ°au’ma™mSVion”r>o"nm
strated in this posture by the insertion under
the ciug'istnura of a wool pad of suitable thickness The exact size must be
determined by trial in each case
NORMAL APPEARANCES IN THE ERECT LATERAL VIEW
In a true lateral ^ lew the gastnc shadow presents a mildly’ bilocular appear*
anco two oial cavities connected by a narrower isthmus It may bo com*
pared With an old fashioned sac purse The upper or fundal loculus slopes
downward and forwards, the lower loculus bangs vertically doimwards This
applies particularly to tlie hypotomc stomach For the hypertonic type there
may be hcen no such biloculation Tlie pylonc canal is not visible in the
true lateral v lew a little rotation mil bnng it into v lew in front of or behind
the stomach Behind the lowerjiole of the stomach will be seen tlie duodenum
and duodeno jejunal flexure.
ALTME^iTAUl TRACT
Tlii>\ic^\ of^\lllcIl o^MnJ, to the relative thickness it is difHcult to obtain
yory sharp radiograms is chiefi} of value in the demonstration of anterior or
posterior wall lesions or to obtain profile views of the stoma and adjacent
loops in cases of gnstro jejunostomj anterior or posterior
THE GASTRIC MUCOSA
The classic description of the gastnc ruga? is as follows
Four longitudinal ruga? two anterior and two postenor, begin at the eardia
and nm down close to the lesser curvature to end at the pjloms These four
are described as forming the magenatraste under the impression that tho>
constitute the channel for
the downward passage of
food to the lower pole to
the exclusion of the rngv}
nearer to the greater curve
This exclusive action of tho
viajenafrasii^ w a myth
Three or four additional
longitudinal rug® on each
wall are descril ed between
the niajenalraaie and tlio
greater curvature Tlieso
begin m tho fundus of the
stomach and end in tho low cr
I olo (Fig 2S) The e longi
tudinal rugTj becoino m
crcs^ingl^ irrogular the
nearer tlioj ire to the greater
curve and show a tendenej
to become broken up into
secondary transverse and
ohlitpio rug® (FipS 2j and
301 Chftoul regards this
aiTnn^emcnt to be static and modified only by the elastic stretching and
vontraction of tlie mucosa ns n whole in rcsjx)n.se to varving distension if
the stomacli
Tilt modirn view Jiowevcr on the form and functions of the gastric
muco V IS based on the rcsearclics of ForaatU In 1023 this worker first
stated his autoplastic theory that of the automatic functional motility of the
gastric mucous niemhmnc and thereby gave a satisfactory reason for the
cxistentx! of the nmsctilans imieosc Prior to his piper that muscular layer
was not known to hav c any significant functional activity Forsielt a theory is
p IG S Von nl m oh l ] attrm i > nfomAcI of nilhpr o
fno tvpp
THE NORMAL STOMACH
53
m brief, that the gastric muco«a can adapt its rug®, in response to the stimulus
of food, mto such a form as is licst suited to promote digestion, and that this
activity 13 a local autonomic response, and not dependent on distant nervous
control Tile particular value of his nork he» m the attention he has dra^n
to the great ^arntlon uhich may occur physiologically, and to the changes
uliich may take place in gastnc disease
Forssells uork extended al<?o to the duodenum, small intestme and colon,
although It is m the stomach
that the phenomena can best
be studied
Berg and Albrecht have
elaborated his i\ ork, and
recently Kadrnla has gnen
an account of the physio
logical changes that may
occur
Chaoul does not accept
Fors^ell 8 \ lews, and holds
that tlie rugosity of the
gastnc mucosa is go\cmed
bj the distension of the
vi3C\i8 but the latter’s vieu s
are probably nearer the
truth It js possible that
both arc to some extent
right , that the longitudinal
rugaj along the lesser curve
are anatomical, that those
near the greater enrae are
autophstjc, and that both
factors control the inter
mwlxoto rmes
Tlie inecbaiii-sm of the
phjsiological changes m the
gastnc rugaj is, according
to ForwU, twofold — the
autonomic activitj of the
nuLScuIans mucosa; and the varying vasculantj of the mucosa and subniucosa
The former determines the number and shape of the folds, and the latter,
bj a vary mg degree of tuiguhty, controls to some extent their size and
coarseness
Aorfriit-a has described tiie following chants m the gastnc mucosa under
X ary mg ph\ siological and pathological states
Fic 2S— Xomwi! mue&'al of alomach duo
<(cnuin on I jejimum
54
ALIMENTARY TRACT
Ph>siological
(1) Modifications pesclttnq fbom Progressivf Distension with
liARii M Emclsion — W hen the stomach is relatively emptv the rtiga; are few
nml coarse As the viscus is fiUe<l the transserse nigce become smaller but
at the same time more numerous Tins occurrence is mesphcable b^ Cfaoiil s
theorv If the gastric ruga; were dependent on the contmctihtv of the
muscular coats distension would
obi joMsly efface them gradual]} but
would not add to their number
(2) MonmcATioNs dxjf to tih
pBtsENCE 01 Food in the Stomach
— This w hen tested bv the addition
of \olL of egg to the thin contrast
meilmin resulted in enlargement of
the mucosal folds and their re
arrangement In this connection
Fora^dl described m tl e dog the
formation of actual mucosal pod ets
surrounding particles of meat to
wlncli he gave the names oiJoaaeUes
or nhfolts diQf^tnca The nnisculans
mucosa? and vascular engorgement
arc botli said to take part in the
formation of these lacuna? Thc'sc
fossettes do not occur in the
human subject E\pcnmcntall\ it
was found that if the ingested meat
IS m coniparatiAcly large fragments
the enlargement of the ruga? is con
siderable m the attempt to engulf
them
(3) Infli encf oi- Entbaneocs
Factors — Cold tends to make the
rugx smaller and more numerous both in the stomach and colon Pilocarpine
tile asme efF'^ iin<} stmptne the <tpp<>site Tite^e tiire Awweser
not constant
In the colon castor oil tends to enlarge the nigse b\ vascular congestion
while saline purges b\ dehydration haAC the rcAenw; effect
Pathological
The changes in the appearance of the gastric mucosa in different diseases
of the stomach are dc'cnbcd under tlieir respcctue headings but may Ik?
siimninri ed as follows
Fic SO — Normal inu -oM*! j fttlem in utonoach
o (I nol n- th rollo Isl banum
THE ^ORJUL STO'VLACH
55
Extrinsic PatsspRE — ^Dfsplacement spreading and duappearanee of the
folds These changes occur onlj when tlie pressure is considerable
Infl.i'Mmation — ^Thickening irregulanty and stifFne^ of the ruga?
Accortlcng to Berg a verrucose stage maj be reached ui chronic inflammation
In atrophic inflammation no change is aisible as a rule In gross atrophy Ihej
mat disappear
Ulcer — Conaergenoe of folds (which maj be thickened) on the crater
Erosions arc usually underaonstrible
>vtOPLASM — Obliteration of the ruga? and irregular piotuberauces and
craters on the growth itself
RATE OF GASTRIC EVACUATION
In the consideration of this there must be noted
(1) The time of commencement of evacuation
(2) The time of c\acuation of the main bulk of the meal
(3) The time of c\ acitalion of every trace of the meal
Variation in the time of oh three mo> occur according to the tj'pe of stomacli
the tjpe of meal and the pylonc function
Taking as a standard the orthotomc stomach a normal pylonc function
and n food free banuin cream as the contrast meal gastric evacuation should
commence in about one minute after mgestion of the meal The mam bulk
of the meal should have left the stomach in an hour and everj trace m two to
three hours Frequently the last time factor is lengthened even m the normal
and there inaj be retained in tfie stomach a small trace of banvim up to six
liour« If tlie abov c first and «:ecoiid time intervals are normal the latter is of
little significance prov ided the patient is fasting and has not been lying dow ii
\ small SIX hour residue is common m hjpotonia and results from gravitj
It can as a rule be freely expressed tlirougli the pylorus by manual pressure
thus diflcrentiating it from a residue due to pyloric obstruction spa<m or
admlasia A poorly suspended banum emulsion tends to produce a streak
residue at the lower pole by sedimentation This is conipletely prevented bv
tlie supine posture and is not seen m cases confineil to bed
IlamhK first laid dowTi the rule that a six hour gastric residue indicates a
pathological condition but tins is tnie only if the residue be of some size say
one fourth to one third of the meal and even then it may lie due merely to
gros.«i hvpotoma and ptosis and not to pvlonc obstruction
The Influence of Various Factors on Castnc Evacuation
(1) Tyte or 'NIial — ^The pre^nce of any food and particularly fat
lengthensallthreetimes Bi ninth in place of barium hasthesameeffect and
l^ said approximately to double the time of evacuation compared with banum
so ALIMENTARY TRACT
{2) Toms of tuf Stomacu — H^pertoniis »pec<ls up the second and tlunl
time mtervak, and hyi>otonia stons them Neither has very much effect
on the time of commencement ofe\acuation, unle^ the lij'potoma Iw m> mnrheil
as to approach atonj
(3) Pfbistalsis of Stomvcii — Tlie degree of pcriital'is influence^ all
three time*> direeth
(4) Pyiobic ru^cnox — Variation m the normal pjlone function affects
nil three jxnnts m the rate of evacuation
(n) Vnilue Paienry — Tins raaj be organic, as in a scirrhous earcinoroa of
the pvlorus or functional, as in a carcinoma not involving the pjlorus or a
simple achjlia In each case the stomach empties rapidly
(h) Achalasia of the Pylom* — This term js nsetl by Hurst to de«cnbe a
condition in which the pylorus rchises infrequently by itself while pressure
rendilv forcesfoodthroughintotheduodenum Itdelaystheevacuationtimes
(c) Pylorosjiasm *--In this reflev condition, most commonly the result of a
gastnc or duodenal ulcer the pylorus la obstinately shut at fin.t, and after
about fifteen minutes commences to rela^ and allow free gastnc eracuation
Pylorospasm therefore affects pnneipally the first time factor, that of com
mencement of evacuation, and the other two to a les«er extent It at fir«t
aimulntea organic obstruction, n simulation disproved by the later course
of evacuation
(rf) Orycime 0£>s<n«c/ion — With this all three tunes are markedly length-
cnwl The hst factor mav spreatl over into the follovnng day a state of
affairs practiealh pathognomoiuc
THE ACT OF VOMITING
If the stomach l>e observed under the screen clunng the act of vomiting the
following sequence of eients is seen
Tlie diapliragti! rises with the increase in abdominal pressure The laxly
and pylonc antrum contract vigorously and the stomach takes on a peg top
sJnpe TJjc fmidas remains dilated and the gas bubble disappears with the
opening of the cardiac sphincter Combinetl contraction of the abdominal
mus( Ics linpiiragm and stomach ejects llic gastnc contents up the oesopliagus
After the act has been completed the stomach gradually relaxes and assumes
its normal contours
CHAPTER VI
GASTRIC ULCER
Radiology iias re^olutiouised the diagno'^ts of peptic ulcer, and its differ-
entiation from other organic disease m the abdomen and from the functional
d58pepsias It has removed this lesion from the realm of diagnostic guess
work and established it as one of the moat easily diagnosed, m the ordinnrj
13^)6 of case
The banuiii meal exammation, if thoroughly and efficiently earned out, is
b} far the most accurate method of iniestigation in suspected peptic ulcer, and
in the majonty of positive cases demonstrates the lesion beyond all doubt
or argument Tina supremacy as a diagnostic method is of comparatively
recent g^o^\th, and is dependent on careful and accurate technique In
tlio hands of the inexpert or careless it can bo so misleading os to be dangerous
This last requires emphasis non in a si aj it did not tu enty 3 ears ago Tn ent}'
years ago, or even later, radiological investigation of the stomach ivas so much
in its infancy that undue reliance u as not placed on its results Non ada} s the
profession has been educated to rely on the accuracy of the radiological method
m organic gastric disease to such an extent that, unless the clinician is also
a ersed in the technical aspect of radiolog3 to some extent, he may be milled b\
inefficient radiological lui estigation m a waj that n ould not have been possible
m the past
Peptic ulcer nia} occur m any of the foUouing sites ccsopliageal, gastric,
pjloric, duodenal, jejunal
Glsophsgeal peptic ulcer is rare, and has been mentioned m the section
on the oesophagus
Gastric and duodenal ulceration are, on the contrarj, common conditions,
and constitute bj far the commonest lesions found b\ X rav exomination of the
stomach and duodenum Of the two, duodenal ulcer is tJie more common.
irnl^on has pointed out the \erj varying ratio between gastric and duo*
dcnal ulcer recorded by different outhonties, which bo quotes as follows
or DU
Irrtvnl
Pick 27 73
Ma/o 20 7-1
24 70
SJ erren 54 50
Unflon 59 41
Il'n/Zon’s figures for duodenal ulcerorefcurpnsinglj low The writer’s figures,
III common with those of inan> other radiologists, arc of the order of 4 to 1
Duodenal and jejunal ulcer are desenbed m their appropnate sections
57
5S
ALniCNTARl TIUCT
PATHOLOGY OF GASTRIC ULCER
Ga«lnc ulcer maj Le acute subacute or chrome It is no« held that nil
pcptjc ulcers of the stomach begin as acute erosions
The acute stace lasts up to three weeks tlien if the ulcer does not
heal becomes subacute and reaohea the elironic stage if it still jiereists m
two montlis
Acute Ulcers or Haemorrhagic Erosions are commonh multijile The\
\ ar\ m sue from a pm head to an inch m diameter maj occur irregularh
distributed amwhere in the stomach but are commonest in the pjlonc half
Tlie\ are shallow and rarely insolre the niuscular coat (Edema may occur
round the ulcer and cause an apparently deep crater The> tend to heal
rapiclls in t«o or three weeks
Subacute Ulcers are merely a teroporart transition stage between the acute
and the chronic They are fewer in number than the acute (most of which
heal) and mat lie single The muscular coat shows commencuig intolvement
and pome basal inflammatort reaction « present
Chrome Gastnc Ulcer — ^Tlits is the type which i* usually presented for
\ rat e\amtnation
They arc usualK single The following ilata have been compiled Hurst
and Sfcirorl
(1) SiNCLE in 07 'a per cent of coses
( 2 ) I’o«iTn>\ —
r rr»M
r me Tftoa }►■•
Ti lino I*
Cerilta 1
Vntenar vbII
} tx^enor trait 3
The lesser cur\c region includes thoac on the antenor and posterior walls
clo^e to the lesiser curve
(3) M7L — ^Tlic average sue m I8G ca«es thev imestigated was 10 x 10 mm
\ccording to the Mato Clime 94 per cent showed a diameter less than 2 5 cm
(4) lorn OF Tilt Ulcer — ^This depends on the stage
n/e/iar/ire the ulcer is dreph exeat ited "ometirac'- globular and with
thiekcmdotcrfiangingeirges Tfic surrounding mucosa cederaatous ff/ien
iidoUiit the thickening and ajtleina of the margin dunimdi but still overliang
until t/e /ffl/n j Majr when the ulcer gmduallv n'<sumes a conical slmpc
( >) Fuxjn or the Ulcer — Mlien the muscular coat is breached granula
tion tissue and later fibrosLs form a new 0oor most commonly in the thickened
pnstn> hepatic omentum The pancreas forms the lied of the ulcer in 4 per
cent of cases and the In er in 1 per cent U hen these structures form the bed
the ulctr i» as a rule shallower than when the gastro hepatic omentum forms
the door
GASTRIC ULCER
oO
(6) Abiiesioss oi THE Xjlcfr Bed — The pentonetmi co% enng tlie floor of
the nicer responds to inflninmntorj imtatioa by a localised plastic pentomtis
causing adhesion» to neighbouniig structures The adhesions maj cause
some ^lefomllt^ and bj retraction of the lesser curve upn ards and to the left
contribute to an hour glass loeulation
RADIOLOGICAL FEATURES OF GASTRIC ULCER
The \ raj signs of gastric ulcer fall mto two classes — direct and indirect
There are man^ indirect signs of varying value There is only one direct sign,
hut it is \irtuallj pathognomonic and will be considered first
THE DIRECT SIGN OF GASTRIC ULCER
Tins consists of the demonstration of the ulcer crater — the niche of
Havdel In its most typical and most easilj demonstrated form it consists
of a ^irotnisiQU of the barium shadow from the Ic ser curve This is at once
oiidcnt when the stomach is hUed wath a contrast mea! It is not necessarj
for tlie ulcer crater to be situated preci'clj on the lesser curac to be so visible
It w ill be seen ei eri if on the antenor or posterior w all if not more than an inch
or so from thele&scr curae if it be man active stage as spasm and cedema bring
It mto profile Again rotation of the patient m the appropriate direction will
show n crater m profile if it lie masked m a true postero anterior mcw (Fig 31)
As a prehminarj how ever to this the most certain demon trition of an ulcer
crater the relief pattern of the gastnc mucosa should be studied
wash method . of Cttlbert Sco it Tlus frequentlj sliow s the ulcer crater ffllcfl
and directs attention to it before filling the stomach completely — a procedure
which III certain cases nnsks a postenor wall ulcer
Appearances of the Crater In the Mucosal Pattern Radiogram
The relief pattern is of particular \olue in the studi of ulcers m sites where
a profile view of the crater is difficult or impossible to obtain such as the
MJtU auidJumr-uearthe/imdiLs The nicer crater visiial
i cd in such a radiogram >vill aarj in its appearance acconlmg to its degree of
actmtj \ssuming that the crater is oil the posterior wall and the ritho
gram taken w itli the patient supine there wall be visible
(1) \ Cfntbu Fefck the bannm filled crater the iacle <i»spendue of
the French
(2) A Zone eolnd Tins Deioid opBarrm — This represents the redenia
toua mucosal lip of the cratbr The width of this zone forms an mdex of the
actintj of the ulcer or more precisely of the surrounding mucosKa! inflamma
tion Tlie wider this transparent zone the greater the cedema
(3) Finally, a Corona ofMi co^tnRroE converging towards the crater
Ihe comergetice again is an index of the chronicitj of tlie ulcer The
/ 3] — lo (rnnr wall uker (nlClmiii \t
j O'lpro-aniCTior %
crater ‘wn in profile nia> present n wdevanetN of ajuieinnc-esdepending on
Its size depth and nctiTitj
Armr Chromc Uixtr — T lie crater filled aith banum appears to be
deep and often infli a rsflier narrower neck ami a rolled-orer edge The
depth ini\ bo w> con iderable that it appears almost certainh to have pene
tnited nj,ht tlirou^li the ga«tnc wall into the pengn«tnc tisanes {Fig 34) At
opention the apiiearances are as a rule verj difTcrent— a conipnmtnelj shallow
G2
\LI^fENTAR\ TRACT
ulcer, Mitli no suspicion of penetration through into the pcngastnc tissue
jTors (II first suggested the erpKnation of this discrepinci
"V ra% e'^aminfttion u^oall^ tahea place dunng or immediateh after an
active phase of the ulcention — is indeed often precipitated bj an especiallv
iKMere bout of dr'pepsia and the stomach w therefore CTanimcd ■nhen its
inucova IS citarrJia! and cedematous round the ulcer
Operatise interference on the other Iniul ns a rule takes place after the
Fn. 31 — Latvp »/"iivr 1 -Mer cun*- ukw with twlpiMtou-* e<l
fisiKVft (}sts oiT of trjtk tk^ rp^ik tkst tke
associated ,.a«tntis and ccdeina of the niuco>ia round the crater has ».ulwdcd
a hen the ulcer js inspected it operation (Fig'i 3 > and 3G)
It !>. then the oedema round the crater that is responsible for its depth
and the degree of the owlema can frequently l>e determined ailh acturac' bv
\ isuih mg the nonnal Ime of the lesser curve It will then be seen that the
deepest part of the crater lies on that line and that the pathological lesser cun e
sweeps well to the left in a 1 luat monnd on the summit of wh«h is the neck
of the crater Tlic estimation of the size of this mucosal hillock is of
03
I'lo 30 — I.C'*»or ct rve ulcer crnfci
ALIMESIAR^ TRACT
W
importnrico ui jiKJjrm" the degree of gastntis and its hcahng under medical
treitment
If as a result of the above factors the ulcer crater is \erj deep locular and
vnth a narrow neck an appearance in the erect position results winch waa^
jircvnouslj described as diagnostic of clitonic perforation and formation of a
jHingastric cavitj Tliree laj era arc then visible in the cavitv — air lluid and
barium — from abo\ c dow n
wards The somewhat clumsy
tenn accessory pocket has
been applied to tins apjiear
ance Tins lamination is also
seen in true perigaatrio cavities
resulting from chrome perfora
tion The\ however tend to
he larger and may not have
the eliaractenstic position of the
former relative to the Ics cr
curve (Fig 37)
A fleck of barium very
tjpicallj remains m the crater
after tlie stomarli has largelv
emptied and when the barium
has sunk well below the level
of the crater It remains in
the crater because of the absence
in the crater of secretory and
peristaltic activity of tl o mus .
culans mucosj} rhese two
factors tend to rid the normal
mucosa of anj coating ofbanuni
hut tlio inert crater has not
the jiower to do so Jndted the residue of hnrnim is often eiocptioiially dense
since the barmm particles tend to settle and silt up the crater
He.«jno CnnoMC Uweh — 4s an ulcer heals clmnges in its \ nj
n^p^pearance take jilace
(1) The cedema of its edge lessens Tins makes tl e ulcer shallower and
widens Its neck
(2) 1 he ulcer licgms to fill up from hetow
The^ two changes tend to give the healing ulcer a 4 shape the angle of the
\ widening as lie din^ progresses Lvcntuallj if as a result of treatment the
as. ociatcd gastritis oiitirclv clears up a shallow rounded crater is left It is
at this stage that it is dilHcult to he certain radiographicallj whether an ulcer
has 1 taled or not The crater mnvlicno more than a niilbmctre or so in depth
GASTRIC ULCER
and anj associated spasm of the greater
cur\ e disappeared Unless the ulcer crater
be viewed tangentinllj to the banum
filled stomach it ma\ well be missetl
and an ulcer pronounced to be healed
wltcn in fact liealing is not complete
(Fig JS)
ilie above proMdes a prettj bone of
contention letween tbe protagonists of
tl c medical and sui^ical metliods of treat
ment of peptic ulcer and the search for a
slnllow ulcer must bo \erj tliorough
lieforc it IS safe to saj that the lesion M
completed heiled
Direct Sign of Ulcers tn Special Sites
P^Lonr'' — For aintomic'il reasons
pjlonc ulcer presents different ndio
gnpliic features from tl ose ciscttlicre
The ulcer being more or less enclosed
in n muscular ring no mucosal adema
can de\ clop and ns a rule no deep crater
Is Msible If a crater be been at all in
tbe p>lonc canal it is usually small and
shallow In ofl er cases the niche mn^
be in the form of a spicule or a tnt\
dircrticuhun If f-cen eii fare a ro ette
appearance (?n cororde) ma\ be seen from
tlio central Heck and the ridnting phcT
More commonlj some distortion tnU of
the canal 15 Msvblc ami associated with it
some defonmtv of the duodenal bulb
Tins di tortion is. marked if llie nicer
crater extends into tl e duodenum as it
not uncommoril} docs In some cases
there is an actual p\ lorosp ism a condition
which makes the demonstration of the
ulcer \er\ difliciilt (Fig 30)
I iNDi s — An ulcer m this rare site is
difficult of direct demonstration It is
most likeh to be been in a relief pattern
nulio,.mm prone or supine Its demon
stration is Jirpeh n niatttr of chance
\ n II — o
'Go
ft 3S — Itpni nRlwtwro ni uteer lakon
at ftionll n «ntcr\ul<
CO
ALniENTABV TRACT
find screen ivamination js necessan to determine tlio jnrticjilar po ition m
which the crater can l>est he seen if at all
Caroia — ^This IS miotliLr rare site 'Hie ulcer is iisuallv situated ]ust
Iwlow the orifice and ma^ ho visible as a niche Jsot uncommonU there is a
projection of the barium shadow m this region from a mucosal fold and it is
lie 3>l— T \lonculc«Tai on
always difficult anil niaj he impossible to iblTerentJate between tlie two
Again just below the cardia is the commonest site of a gastric diicrticiilum
winch rnaj nl o le mistaken for an ulcer crater
INDIRECT SIGNS OF GASTRIC ULCER
Castrospasm
Ihi^ is the coinnioncst indirect \ ra\ sign of gastric ukcr
It JS cither circumscrihed or regionnrj If the ulcer he on the lesser cun e
the most jural sjnsni is a JocaJjscd mtcli on the greater ctine oj jK)«itD t) c
ulcer Thisnotclior mcisiira maj be shallow or inaj extend almost to tlie
Jc*'ser cttr\e and produce a pure spastic hourglass stomach of the R tjpe
(hip 40) While iisuallv opposite the ulcer crater it is not invanihh so
aiidmaj occur cither above or below it Tlic latter is tlie commoner variation
Sometimes instead of a single notch there ma^ bo prev'iit a senes of
notthesofvarvingdcpth The deepest is iisimlU at the centre of the grouji and
those on cither side gradually dimimsh in depth (I :g 41) Again tl erema^ he
GASTRIC ULCER
07
a senes of small indentations of equal width spread along the greater cur\e
Such intisuraj must ho distinguished from two other conditions giving a some
what similar appearance Thickening of the mucosal 'rugie in a not too
completely filled stomach is the one which most closely •simulates it Indeed,
rugal thickening from chronic gastntis m a not uncommon accompaniment of
gastric ulcer and both a spastic mcisum ntid notching from mucosal tliicl cning
Flo 40 — Lnrpo lens<*r curve ulcer with epibit o I our KlftM deforn) tv
Dcformcil <i lo lenal bulb freni of I ulceration
mas be present together in a case of ulcer of the lesser curve The notching
of the greater curse bj increase m the ruga? is a aerj common accompaniment of
jxjptic ulcer an>wliere it represents a reRe\ mucosa! phenomenon and is
npth descnlieil bj the Oermnns in the term Zuhnelung The other cause of
indentation of the gioater cune— eatnnsio presiure from a gas filled splenic
(Ic'ciire — produces a coarser and less negnlar indentation
In the so called orgnme hourglass contracture a large amount of the
dtformita is due to spasm Indeed in mana of the casc•^ of hour glass stomach
ALDfEIO’ARY TRACT
in Mhich tfiere are t«o compictth separate loculi, with a long narrow channel
of comnmnication, the defonmtj maj be entirely spastic Aa a rule, howei er,
these grosi,er forms of hour glass contracture are partly organic and parth
spastic A feature of tliese contractures is the sagging of the upper jKjuch well
below the lc\cl of the ulcer and commiimcating canal, due to the obhquitj of
the contracted muscle fibres
In contradistinction to this is
the \ sha|)od hourglass of
acirrhous carcinoma
In cases of pi lone or
juata pjlonc nlcemtion a
regional spasm ma^ occur
of the paloric antrum It is
ti>inllj associated with a
p\ lorospism and appcain as
a 1 ick of filling oftlie antnim
close to the pjlorus A
rather longer spastu con
Iracture of the p>}onc an
tnim is eomnionh teen in
ga-sfnHs or ulcer follow mg
gastro jejunostoms
ISTRrssic OB E\TPrssrc
(•\sTnosP\sM — Cnrwflii
held that these two tjpes
could l>e differentiated b}
administration of belladonna
or atropine Hii* aiew was
that if the spasm be intrinsic
exhihition of atropine to full
phssiologital effect would
not alFeet it while it would
abolish a gastrospasni due
tfi such t luses as duodenal
t.a-tntv.anlpn«tro,|,#,ii* clirOlllO apllCnillCltH
denies that atropine has
this selective piopcrta The test baa fallen out of ii-o now l>erausc of its
unccrtainta and more particiilnrh because withimproacdtechnniuc of recent
icars the diRct demonstration of the lesion is more certain In addition the
jiroiedure is unpleasant for the jiaticnt ns the drug has to be pushed to full
phaniiacologicnl clTect Ilenzedniie sulphate mg 10 30 is said to l>e cficctne
in abolishing gastrospasm
GASTRIC ULCER
CO
Abnormalities in Size, Tone, Peristalsis, and Rate of Emptying
At fir>t sight changes in the above properties of the stomach show a
bewildering ^a^et^ and irre^lanty Anv attempts to coordinate them
directlv with the tvpo of ulcer crater pro\e unsuctcssfiil In one t.n«e n le» er
curve ulcer is associated with liyTiertonus hj perpenstalsis and rapid empt^ mg
and in another the re\erse The same is tnie of the similar so called secondary
signs of duodenal ulcer In reality thev are not strictly ^igns of ulcer at all
Ilitrsl has pointed out that if the above changes lie considered relatively to the
pylonc function some order emcees from the chaotic vanetv He group"'
ulcers of the stomach as follows
(1) Ga<;tric Ulclr vvrrir Xormal Pvioric Flnctios (uIcu-* smiplev)
(2) G vsTRic Ulcer vvmt Pvloric Acu\lasi\ — In this the untnl ojiemng
of the pylorus is htcr than normal and the periodic relavations are mfrerjueiit
and relatively ineffective Relaxation can l>c assisted by palpatory pressure
and a normal amount of the contrast medium forced into the duodenum
Ilttnt describes pylonc achalasia as a rcflcA mhihitjon of relaxation resulting
also from a remote abdominal lesion such as an appendicular or a biharv focus
of irritation
(3) C> VSTRIC Ulcer with Rvlorospasm — In this combtion none of the
meal can be forced through the pylonis The condition sminlstes pvlono
ohstruction in the early stages of the examination and hter rehxes to 111011
the stomach to empty
(4) Ct vbTRic U LCER WITH Pv LORic Orstrlction 111 w liich the py loru-s fail",
to ojicn normalh at all
In the study of tlie pylonc function note must be made of any tnnHiwreiit
contents nlreidy m the stonneh when the opaque meal is given fhe barium
meal usunllv divides such contents into two portions the smaller of which
passes into the py lone antrum and u> trappccl there as m a U tube Tlie major
portion lloats up on top of the opaque meal m the gastric fundus The former
lc"'ser moiety must pass out of the pylonc antrum into the duodenum before the
pylonc ring and duodenal bulb can be visualised This state of affairs musl bo
tfistinguisfiecf from the abov e meiitioned pv fonc ahnormahtics incf can Oe bv
noting m the jiylonc nntnim dunng a phase of relaxation the honrontal fluid
level made by the contact of trapiicd fluid and opaque medium
Size and Tone of Stomach in Gastric Ulcer
(1) Ulci s '^IMPLEX — \ simple ulcer witliout change in thepy lone function
had no mfUienec in gastric tone The presence of hvpcrtonus or hvjiotonus
depends on the habitus of the patient and not on the ulcer In actual practice
hv iKjtonm is v erv commonly present in casex of gastne ulcer — in 00 |)er cent
accxirding to AoAfer — and hypertonux much less conmionlv
This Iftirsl explains by ascnbmg to the gastric habitus a determining
70
AL1MFXTAII\ IRACT
effect on tJic site of the ulcer Tims a pre-e^isting hj pertonua tends to localise
a peptic ulcer m the duodenum, ulnle hjpotomu tends to the development of
the ulcer in the stomach Hurst regards tins as an important factor m the
localisation of the ulcer, particulatl> duodenal ulceration The writer is not
convinced that this la true
(2) UixjEn wiTU PiLonic Aciiai^asta — ^T his likewise lias no effect on
gastric size and tone
(3) Ulcer with PiLonosrwi — Increase in sire and lessened tone result
(4) Ulcer with Piloric Obstruction — Ihe hvpotoma is marked and
develops into atonj and marked gnstnc dilatation
Peristalsis m Gastric Ulcer
This again dejicnds largely on the pyloric function and on the patient s
habitus
In simple ulcer, or in one witli asaociatctl pvlono achalasia, peristalsis is
unaffected In one with pjlorospism peristalsis is incrcabcd at first and later
diminished If the pj lotus be obstructed, gross initial hj perperistnlsis is the
rule, the dilated stomacli wTithing with wide deep pcristnltio waves In a
short time after ingestion of tlie meal this is replaced b} aponstalsis and aton>
Rate of Gastric Evacuation in Gastric Ulcer
This will depend on the factors already considered, namely tone penstalais,
and pjlonc function, but it is n serj common feature in lesser cunc ulcer to
find a small bin hour residue in the stomach This should bo tested fasting
The residue maj be due to hj'potonia, to pylorospasm or to pylonc stenosis
In those cases in winch it is due to hypotonia the stomach empties freely in
the early stage of evacuation, but seems unable to nd itself of the residual pool
of barium in its lower jiclc The persistence of the residue is postural in cause
If the patient assumes tfie horizontal posture during the six hour period,
complete gastric e\ acuation occurs m norranl time \\ hen the gastric delay
in evacuation is due to disturbance of the pylonc function, tins wall be apparent
on screen exammation immediately after the meal is taken when the jiylonc
disfunction will show itself
Localised Tenderness on Pressure
This IS a sign on wJiich stress useil to belaid, but one which has ceased to 1«
of importance since direct demonstration of the ulcer crater became the
desideratum If there bo persistent and localised tendeniess on pressure over
an ulcer crater, such tendeniess is obviously an indirect sign of ulcer, but one
which is of little miiKirtanco in view of the visible crater itself In the absence
of a crater or deformity, the sign is so uncertain ns to l>e valueless It would,
however, lie of significnncc if fcnnd over a localised area in the lesser curve
GASTRIC ULCER
71
with a corresponding incisura on the greater cime If a tender point be
present, and known to be due to an ulcer, its %alue is that it indicates an
active stage of the ulcerative process It is commonly held to be due to
V tsceral tension in the ulcerated area protiuced by the iialpating finger
This indirect sign becomes relatively more important in areas uhero it is
difficult to demonstrate the ulcer crater — e g pj lone and gastro jejunal ulcers
— but it IS a sign of no great certainty Its localisation must be meticulous
and Its interpretation guarded
Fraenkel’s Sign, or “ Peristaltic Jump ’*
This sign Mould be of importance if it could be demonstrated easily*
It consists of an interruption of the ponstaltic \va\ e on the lesser curve bj the
ulcerated area The latter takes no part m the u'at c, which begins agam on
the distal side of the lesion It uasslioun first bj Frdnlelm a rapid senes of
films by superimposit ion The sign is of greater importance m early carcinoma,
or Mill be uhen advances m cineratbograpluc technique allon it to be easilj
and accuratelj demonstrated
Segmeotal Rigidity and Straightness of the Lesser Curve
Duval Deux, and DecUre laj stress on the«e as signs of ulcer somewhere
m the stomach Fcnstaltic sinuosit> is absent, according to these authors,
for a ^'anablc length on cither or both sides of a niche on the lesser curve It
18 a sign tbfiicult to detect uith certainty, ami ubile, if it is seen, it should rai&e
the suspicion of ulcer, by itself it can do no more diagnostically
CICATRICIAL SIGNS OF GASTRIC ULCER
These are three in number py lone stenosis, organic hour glass contracture,
and contracture of the gastro hepatic omentum
Pyloric Stenosis
Three stages can be made out m chronic pyloric stenosis from the scamng
of an ulcer
First St«3F CoirrEvsATro — In tlus stage the stomach shows little or
no dilatation, peristalsis is acti\e but not excessively so, and evacuation takes
place slowly but fairly efficiently In this stage it is usually possible to
demonstrate the narrow ed py lone canal In order to do so, it is essential that
the stomach lie empty, as retained •secretion and food make it impossible to
fill the canal with banum
Second Stage of Faiuno CoMTEssATroN — Considerable gastric dilata-
tion IS prc'^ent Initial liyperpcnstalsis is excessive, and bucceeded by atony
ns the pastnc imisculature tires
A pyloric stenosis which has reached a developed second stage presents
\ery tharactcnstic features on banum meal examination
GASTRIC ULCER
73
On screen examination m the erect position tite first abnormality that
strikes the observer is the mode of iilhng of the stomach The barium is seen
cithcrto slide dottii the les«ercur\e to the lower pole or much marecommonh
to drop in round blobs through transparen t flui d contentb ahead\ in th e^
stomaclT U\en \rith carctut pre^ration and withholding ol food or liquid
ibr hours before tbe examination the stomach will be found to contain quite
tio 44 — Soscnlour gastric r^ijiie m pvlorii ol'«truclion tie wile i ool of
ob-trtiction
II largo amount of liquid (Fig 42) chiefly swallowed salita and renting
gastnc juice
As soon as the stomach becomes jiartly filled \igorous livperperistaWis
sots in the waxes being deep and wide A characteristic of them is that
the lesser curxo also shows deep pcnstoUic indentations equal in mignitudo
to those on the greater ccirxe This large wnxe hj £icrperistalsis is seen only
m pylonc obstruction (Fig 43) flic large size is due to the gastric dilata
tion In non-obstnictno hy perpenstalais the xtaxes are smaller and more
numerous
In this stage of stenosis it is not always jiosMble to demonstrate the |nJone
canal itself If jiossible at all the prone position is the best in xxhtch to show
It In that position a imirow «:treak of lianiim max sometimes be seen m the
steno cd passage
tio — Pj lorn, obstniclion witli inaikwl thlntattCHi im 1 ^3 Pjlono ol »
ipotonm Tran$pHronlcoiitcntsoec\iIiy tii«| ai'sinorl a al o\e li>'ppq
GASTRIC ULCER
73
On screen esamination in the erect position tlie first 'ibnornialit 3 tint
strikes the observer is the mode of filling of the stomach Tlie banura is seen
either to slide don*n the le'^scr curve to the lower pole or niucli more coramonl} ,
to drop in round blobs thro ugh transparen t fluid contents already m the
stomach' Liveri with careful preparation ami withholding of food or hquid
for hours before the examination the stomach wall be found to contain quite
Fio 44 — S^rn J our gamine due in pilonc ob'itnjet on tl o tri ic pool of
ob><rt cl ton
a Jaige amount of liquid {Fig -12) clucflv swnllowetl sahva and resting
^castnc^iuicc
As soon us the stomacli beconica partly filled vigorou-j hv j>erpenstal«is
sets m the v\avo> being deep and wide \ characteristic of them is that
the lesser curve also shows deep penstaltie indentations equal in magnitude
to tliose on the greater curve Thw large wave h^perpenstalsis is seen onlv
in pylonc obstruction (Fig 43) Tlie large size is due to the gastm dihta
tion In non obstructive hjqierpenstal u> the waves arc smaller and more
numerous
In this stage of stenosis it is not always po>.sibIc to demonstrate the pv lom
canal itself If j>ossib)e at all the prone position is the beet m which to show
it In that position a narrow streak of banum mav sometimes bt seen m tiie
stenosetl passage
74
ALIJIENTAm TRACT
After a vanable but usualH short tune the g'lstric h^perpenstalsis dje4
tloM 11 and l^TXitoma sets m until themg^tion ol a further meal excites \ jgorous
peristalsis again In the In potomc stage the stomach Mill «:how m the erect
position apoolofbanumattheloucrpole topped bj transparent fliucl (Fig 44)
It i« cliamcteristicallj mde and shallow as n result of the gastnc dilatation In
contradistinction to this the residue m simple non-obstructne hj’potoma is
deejier extends le«a from side to side and more nearly approximates to a
semicircular shape
The final point m the diagnosis of pjlonc stenosis is the amount of the
residue and its duration So far as the duration is concerned a six or seven
hour residue maj result from simple ptosis and hj potonii pylorospasm or
stenosis The size and shai>e of the residue may give a clue to the type If
however there is a gastric residue at the twentj fourth hour the condition is
almost certamlv one of organic stenosis A twenty four residue is virtualK
pathognomonic of considerable organic narrowang of the pjJorus
In milder degrees A'here there is a residue only to six to eight hours and
doubt arises as to whether the delav is due to gastroptosis the postural test
ma\ be applied by lastnictmg the jwtient to remain recumbent after taking
the meal Tins vriH abolish the deh> due to ptosis but will have little effect
on that due to p>ioric stenosis
Tinno Stage CoiirLBiE Atoni of the stomach is approached Imtial
{leriataUis is not a marked feature while dilatation is The stenosis is so
marked as to cause almost complete obatniction and the stomach is emptied
chicflj bj vomiting Little con pass via the pjlonis
In this stage there niaj be little or no twentx four hour gastnc residue, os
all the bamim maj have Wn vomited and enqulr^ should be made as to this
factor in ca^es of gross pj lone stenosis
Differential Diagnosis — From the above it w ill be seen that pylonc stenosis
or obstniction whatever its caii«e giscs » tvpicnJ clear-cut radiological
picture in its sarious stages Its diagnosis is simple but the detcrmmation
of the preci e cause is often difficult and nia^ be impovaible
There are howeser certain points which max help in the differential
dingno-iiis lietween post ulcerative stenosis and the other tvpes
(J) Pn.ORo«PA‘!M — This slthougb not a stenosis moj simulate it at fir«t
view It can nn^e from inanj causes such as peptic ulcer any^^here in the
stomach or duodenum cholet^stitis pincreatic renal and appendicular
lesions Stasis in the stomach maj result hut it is usuallv onlj an initial
dclaj in emptjing Tlie Injicrpcnstalsis dilatation and aton\ of the type
descnbctl above are ab«ent and the condition is inconstant A deciding
point lies m the demonstration at some stage in the examination of a normal
pvJoric canal ^\hen the pxlomspasni is asMicjatcd mth a pylonc or
juxtapxlonc inflammatorj lesion it wnll usually be impossible at first
sight to apiwrtion the amount of the obstruction due to the spasm and
GASTRIC ULCER
75
ccdemn, and tint due to {>ermanent scarring When there are ohmca!
indications that the lesion is in the pylorus, it is worth while applying the
therapeutic test, by placing the patient under a strict medical regime for
some ■weeks What was prcMousIy a twcntj four hour stasis may be reduced
to a se\ en- to ten lioiir stasis, or the size of the tirentj four liour residue maj
be dmimi>^hed More accurate information as to the need for operation
IS then available
(2) Stcnosts A^D OnsTRrenos mow Tumours — Carcinoma is nearl.v
always the tumour responsible It may produce general gastnc signs identical
with those of simple stenosis The dilatation is not usually so great, but
additional signs are often present
(a) The so called amputation of the pylorus The pvlonis and prepylonc
region are not \isiblc at first This is followed bj filling of
(h) The stenosed passage which may be narrow, tortuous, and constant
in its form
(3) H\rERTRorrac Stenosis of the Pt lorus of Adults — Tlie character-
istics of this rare condition are dcs»cribe<l later
Although the differential diagnosis ma^ lie dilHcult, an attempt to find the
precise cause should always be made, forpuqioses of treatment A carcinoma
IS an urgenej, while even if gastrojejunostomy is contemplated m simple
obstruction some weeks of strict medical treatment is an obnotislj desirable
preliminary to operation
Hour-glass Contracture of the Stomach
Used m its viidcst sen«e — that of a biloculation of the stomach — the
tcnii includes a vanctj of conditions Tho following list includes the
majority of these , some require no further mention and others some detailed
description
(1) Without Oboamc Stenosis
(а) Pht/itolof/KaJ, the result of marked hyiiotonja The appearance of this
is characteristic, a gentle narrowing in the pars media Occasionallj , in
women VMtli verj thm waists, this narrowing niaj be quite abrupt in the
greater curve
(б) Physiological Cascade Slainach
(c) Due to exlnnstc presture from tumours of the spleen, pancreas, left
kidnej, etc, and particularly from a gas filled colon In the last named
type, particular note should be made of the gas filled colon nsing in front
of the liver This produces the most marked degree of this tyjie of bilocu
lation, and borders on the state doenbed under chrome intermittent roh ulus
of the stomach
7G
ALniFT»T\K\ TRACT
Tliej allsliott di tingiii«hifigcharactens.tics tJiejr smooth
pontours and nn intact gastric mucosa
(if) Pure bpasUc Biloculaiion — This has alread\ been descnbed under the
signs of gastric ulcer It nmj al-so occur as a rtfle\ spasm from Inliarr,
appendicular and other a
mote abdominal lesions and
IS said to occur in chronic
tobacco poisoning
(-2) It rni OncAMC "^TEsosis
Sim; le Cicatricinl Hour
fjhi'tCoutractiire — ^Tlie forms
which simple organic hour
gb&s contracture mat take
are man\ and \nricd de
ponding on the precis? degicc
and site of the scarring hut
mo t of these present certain
common charactenstics bt
tthich thet can lie dis
tmgm&hc<l from the caremo
matous \anetj (Tigs Jo
and 4C)
(fl) Tlie contracture i>
nearlj always at the expense
of the greater curte and
the i&thmus is at the lesser
cune — this gites the 13
slm])c so often referred to
(h) The lotter pole of the
upper loculus is almost in
\ariahlj considcral belon
> o -J> me iktr thio rglAAxrontratCure the JeteJ of thc IsthlllUS
fc) The isthmus is iisualK
m tlu middle tliird of the stomach ainl its point of ongui frecjucntl> coincides
with an netue ulcer on the lesser cur\c In other cases it maj be a little
bel( w an lutivc ulcer liiiMtig been caused be n healed ulcer below the
nttne otic (Tig -17) nie caifibro of the stenosis aanes greath in difierent
caMM and it is imjxjrtant to note the width seen in the racLograms and
also to ob«er\e the rate at which the nical iwisscs from the upper to the
lower loculus In sexcre oases the lower loculus max not fill for half an liour
and there max occur stasis in the upper loculus up to txxentj four hours
GASTRIC l/LCER
77
Detaj of this order usually meam
lonsulerable eicatncial stenosis n
leaser degree can houe\er be pro
cluced bj spasm superadded on a
bilocuhtion uith quite a ande
isthmus Tins maj be testeil bj
subsequent examination after a
few ceks of rigorous medical
treatment The latter max relax
the spasm and reveal the true
degree of the organic narrowing
Exhibition of benzedrine sulphato
may help in the dilTcrcntiations
Tlic length of the isthmus maj be
from i to *1 inches
Stasis may occur m the lower
loculus depending on the pjlonc
function — cither from pj lorospasm
or organic stenosis there It is of
importanco to estimate the mobilit)
of the btenosed channel since
adhesions to the hrer or pancieos
arc common and add to the difficulty
of a partial gastrectomy
Ihe obsorxer on meeting with
ft case of organic hour glass con
tiacture should not rest content
with its demonstration but should
take all possible steps to show
whether there is an actuc ulcer
associated with it cither on the
lesser uiirve pylorus or duodenum
frincc the presence of an active lesion
may influence the choice Iictwccn
medical and sur^jical measures
Fa. — Le>t,prcun tr 1 Iror ai tt ur
PontrBc,tvirf
Mdhgnanl Organic Ilouryhss Cow/rar/Wrc— Ihis is desenhed under the
•>cction on carcinoma of the stoinneb
Gastric Adhesions
Gastne adliesions may give radiological e\idenc-e of their existence by
lessened inobilitv or di placement of the stomadi or by distortion of its
contour (Figs 48 and 49) but manx of the smiplcr adhoMons cause no x i«iblo
chnngi s
afi«T flll DR II '
Fio 49 — Lciftpr rune (•>•) I our glass contracture an 1
<loromui^ R ll o* ons of tl e gastro 1 p| atic omentura
appennincc, such ns ulcer of the lesser curve with contracture of the gastro
hepatic omentum or gastnc neoplasm Jt is said that extensive deforming
tidhcsjons can simulate the latter
CHATTER XU
OTHER INTU\'\niATOR\ LI^SIONS OF THE STOMACH
GASTRITIS
It will be "wn from Chapter II tbit in attempting to ftsscsi the pathological
«iiinificanco of altcntion in the form of the gnstnc nigi? tIio«e changes due to
plusiological and other factors must be <li'«eounted This applies partitularlv
in cn«es of gastritis in Mhicb the gistnc rugTj are said to be thickened ngid
and tortuous It i-*
iisiiall> a matter of the
greatest difficult to«a\
whether a gi\en degree
of rHgo«jtt of the gis
tnc mucoxi is pln-iolo
gical or pathological
pirticularlj when the
folds are usualK «con
onh until the stomach
rcIatiNcl} empt} and in
'the present state of our
knou ledge of the radio
logical apiiearam-e it is
in mobt crises uise to
refrain from such a
diagnosis on a relief
pittern of the seim
collapsed stomach
nlone If lion cier
this appirent thicken
ing and tortuositj arc
uccompanied hj a ere
nation of the greater
curie M h e n the
stomach is filleil \nth a
barium cream containing no fooi! the diagnosis of ga<tntis recenes more sup
IS)rt \iconhng to Aiicfri ia «ol>«enationsthc nigT should then lie small and
‘‘liouldcau«enoindentntionoflliegrentercune TIils of course isuplicldbi
the npivarancT in the normal stomach m the lost imjoriti of examinations
SO
OTHER IXFLAADIATORY LESIONS OP THE STO'MACH 81
It Sihoulcl l>e l)orne
ni minfl that Die com
monest c-iH'O of crciia
tion of the greater
cur\e 3'< a pcpUc iifrcr
(Figs oO atul ol) ami
onij after the moat rig
orous ficarch has failed
to disclose an ulcci
crater should the milder
legion gastritis bediag
no«c<l
Ptriaiia^fojnoftc
iritis la a common
sequela of g a a t r o
jejunostomj in those
ciscs in uhtcli the acid
tuno reniams iugh
and the mucosal pat
tem maj gi\o some
indication of this
^gain the same difii
ciilt> an-cs fcincc the
gastric mucosal pattern
13 froquentis tntiier
coarse in the normallj
functioning gastro
enterostomy Other
signs are therefore
iieccsnarj , such as
stomal ulcer or stcnosia
jejtmitis teneferne^s
oier the stoma and
the clinical sc mptom complex before such a ease can safely lie labelled ns
one of gastritis
ATROPHIC GASTRITIS
(7 1 cldc has gi\cn account of the apjiearances of the gastrie mucosa m
fcimple ach>ha gastnea and Addisons amimn
The nmjonty of the former cases t'hotteil no change from the normal In
the few cases in ultich thcu*5naniii>ertonu-»wasrephce<lbi atom anirroirmg
of tiic folds uas noted and in one or two cases a thickening
In the atrophic gastritis of Adduon s an’cmia the mucous relief pattern
was normal in most and m a few the nigic were coai'sencd
\ n H— C
82
AL^A1E^T\RY TRACT
J^orcimncec-in tliereforo be placed on tbc relief pattern in atropine gastntjs
This maj be deduced a pnort from the pathological change The atrophi
ittiohes pnucipalU the cpithchal la3er, and the niii«cul«ns mucos'c and
\e‘csels of the submucosa Mhich con^stitutc the autoplastic mechanism are
uiiafToctcd Probablv fcuch \anable abnormalities which liase licen noted
m thcve caves are not produced b\ the attophs at all but b^" vome other
incidental factor
PLASTIC L1MTI5
(Syn cirrhosis of the btomaeh , fibromatosis of the stomach leather bottle
stomacli )
History — Firet named cirrhosis of the stomach by Andral m 18-15 it was
desenhed nccumteU Brinton in 1859 It has b^n studied in detail by
d^ej'ia Thomson
i^tiology — Thcie has been considerable difTerenee of opinion regarding
tins Some ca«es presenting the clinical radiological and naked-eje patbo
logical features of linitis pinstica hare tumeil out to be diffuse scirrhous carci
noma and ba philus can produce a similar macroscopic appearance Excluding
these there reniams a group which according to J’Aom.iciJi are due to infection
spreading from an ulcer It is a disease of adult life
Pathology — The condition consi«ts of a (liffu«e spreading fibrosis of the
submucosa starting usually at the pylonc region TJie niuseulans is inrohcd
in the fibrotic change to a le^s extent and the gastne cajacitj is tlimimdied
Radiological Features — ^The diminished gastric capacitv is immodiatch
evident on screen examination Tlic diminution take** place particularly at
the p\ lone end of the stomach and is Ic'^ marked as the fundus is reached
The stomach is rchtireh apenstaltic The pvloric canal iniohed in the
fihro«is remains widely patent and the meal pouts rapulU into the «niaU
intestine The appearance of the niucooal pattern is variable If the mucou'*
membrane is relativcU umnvohed m the fibrotic process the nipaiare rendered
nu re pnunincnt bv the c-ontroclion of the gastric lumen If the inuco«a is
atrophic the rug-e gradually di*«ippear
As in an\ case of marked diminution in the gastric c-apacitj compenva
tors a^oyiliageal dilatation max lake place particoilarly if the ynlonis l»e
not gaping
riie contour of the stomach shows a mild urcgulantx onh depending on
the distnhiitjon of the fibro«is
It will lie seen that it is quite impossible to distingmsh radiologicallx
betweeu the carcinomatous syphilitic and iiifectuc types of Imitis pla«tica
Even where the \\a.ssennami reaction Ins excluded the sjwcific form the
carcinomatous i«sue remains m Midi doubt ns to make lajiarotomy aiiiisablc
in all cases where there is hope of a successful gostrectonix
OTHER I^FEA-NntAlORY LESIO^^S OF THE STO^rACH 83
SYPHILIS OF THE STOMACH
Incidence — Terd irj syphilitic lesions of the stomach congenital and
acquired are e\tremel> rare occurrences m England Onij one 'luthcntic case
(3 /cA€C 5) has been published in this countr> It is reputed to be common in
Churn and Russia Easlerbrool gi\es an incidence in America of 0 3 per
cent of 2 500 cases of gastric ulcer operated on at the Mojo Clinic
Pathology — The disease begins ns an iiifiltration in the submucous tissue
and may be diffuse or localised Ulceration and contracture soon supe^^ ene
The ulcers arc frequently multiple and associated with hyperplasia of the
gistric wall The pylonc antrum is the commonest site of the condition
Radiological Features —In a condition with such protean morbid anatomy,
the radiographic picture is bound to be \aned LeUafd has described the
following types
(1) GEJ.LRAUStD IvriLTnATios producing A stomacli markedly dimmished
in size with rapid emptying and compensatory cesoplngectasia Peristalsis is
diminished or absent Tlio combtion closely simulates bnitis plnstica and
genemhsed scirrlious carcinoma
(2) Tin Dumr dlll UerORinn tesultmg from fairly gMumetneol mfil
tmtion and contracture of the pars media A large annular senrhoua carcinoma
produces the same deformity and this type is usually diagnosed as such
(3) Localislo Areas of IsnLTRATios as© ULCEnATiov m the stomncli
Tins type simulates iv fungus carcinoma
(4) Locaused PiLORic iND PurrvLORrc IsFiLTnATiov which tends early
to produce stenosis It producc5> n filling defect \er 5 similar to that of a
scirrhous carcinoma
The differential diagnosis tictwecn gastric syplnhs and the other lesions
which it nuvv simulate cannot be made on the radiographic BMdence Due
attention must be paid to signs of syphilis congemtal or acquired elsewhere
and to the iVassermami reaction A final proof is the result of vigorous
antisyphihtic treatment In a number of cases reported by ZeUafd resfitt/t/o
latpy/riun has radiojrnjilucally sjieaking taken jihce after some months of
treatment Tins obiiously is too lengthy a procedure to adopt as a diag
nostic measure with a carcinoma as the probable altcniativo diagnosis unless
the lesion is so adinnced as to be inoperable if it is malignant
TUBERCULOSIS OF THE STOMACH
This H always sciomlan to tnljcrculosis elsewhere most often pulmonary
next in frequency intestinal It is usually a terminal stage in the course of a
tuberculous iUncs.s and as such rarcU reaches an ray department Jiroders
has collected 30li recorded cases and has grouped them into two types
(1) Hypertrophic (20 per cent ) — Tins tape usually occurs in the pyloric
region and produces lirgo filling defects aery similar to tho«o of nn cn
cephaloid carcinoma
S4 ALDIENT4R^ TRACT
(2) Ulcerahve (80 per ctnt ) — Tlie ulcer iiaUall\ on the lesser cune
There ire no (hstinmnshing radrological fraturca hthtecn it and simple ulcer
except that it temK to lie larger
Reliance must thus be jilaeod on the presence of tuberculosis el-s?uhcre in
the bodi in the differential diagnosis of gastric tulierculosi-^
ACTINO'IYCOSIS OF THE STOMACH
This is of extreme raritv SrAin: has recorded i ta«e m which the gastric
hunen was eon«ulerabh narrowed and irregular in contour It «imulatetl a
rather ragged scirrhous carcinoma Behring describes a case of actmomjco is
of the p\ lorn's and adjacent duodenum which gase a radiograi»hic picture of
pi lone oh-^tniction He resnews the literature and notes eight ease- of which
onh three were pnmara in the Riomach and one in the duodenum In one of
the gastric cases the railiographic diagnosis was lesscr curve ulcer an 1 in the
other two carcinoma
On considering the macroscopic pathology of the tluease one would expect
to find irregular filUng defects rigiditv of the gastric wall and diminution of
the gastric capacitv all of which would render a radiographic diagnosis of
carcinoma inevitable
GASTRIC FISTUL/E
External Ftstulae
These inav result from trauma — woundn or operations — or from patho
logical lessions such as subacute |»erforation of a gnstne ulcer
Tliej are best demonstrate<l radiographicalh bv an injection of an ojiaque
crcamorhpiodolintothcopemng lfthetrackletortuou« stereoscopM ofhelp
mdemonstratinj, its ramifications Inordcrto prevent the contrast medium from
leakiOp awav externalh tlie sinus should be sealed with adhesive pla ter im
mediatelv nftertheinjection Tnotherca-scsitmov benece -sarv toKeepupprex
pure from the injecting svnnge in order to en uro that the track i& filled when the
radiogram is taken A rublx?r tipped urethra! svnnge is an advantage here
Bv the^ means the track of the fistula can as a nile lx? traced down to the
V1SCU3 with which it communiratca In these fistula? a satisfactorv vaew mav
tometimes be obtained bv taking o tangential vievi after fillmg the stomach
vMth barium cream and the fistula from the outer opemng if neee^Narj
Internal Fistuls
Tlie~c mav Ixs the re«ult of trauma (tiauallj operative) or disease T1 e
w)lon the other viscns mo-t commonh involved rarelv thegall hUdderand
other viscera
Gastho-couc Ft'>TtLA IS usuallv the n-ault of caremoma most often of the
stomach and much less frequently of the colon Less comnionlv it is the result
of simple ulcer tul»erculosis of the colon or following gastro-jejuno<tomv
Gastbo Jwrvo COLIC Itstila — ^\ hile gastro jejimastomv mav lx? the
cause of gastro cxihc fi tula the end result h more commoniv a jejuno-cohe
OTHER IMLA3nU10R\ LESIONS OP THE STOMACH 8o
jla from the perforation of a jojunal ulcer into the trans\ erse colon Thn
vntli the already cxjstmg gastro jejunostomv forma a gastro jejuno colic fistula
Although gastro coLc and gastro jojuno colic fistula? usmllj give a hi torj
that IS almost diagnostic the diagnosis is made clear hi X nj esammation
Either a hanum meal or a hamim enema ma\ demonstrate the lesion I ut the
latter method is epneher and much more certain Sometimes the enema sliou a
the state of affairs clearly after the banum meal Ins faded to do so
The baratm enefna appearances arc quite characteristic The colon fills
normaUv with the enema as far as the tranaierso colon Then depending on
tiio tj'pe the enema floods the jejunum and stomach or the stomacli alone
As the patient la Ijnng supine whde the enema is being run in the gastric
fundus fills up m a wa;^ that leaaes no doubt as to the nature of the condition
The presence or absence of jejunal flooding determines whether the fistula
IS gastro jejuno cohe or gastro colic
It js of importance to he able to indicate the cause of the fistula The
detection of a colomc or a gastnc fillmg defect indicates carcinoma as a cause
Here the hanum meal is of value so far ns the stomach is concerned The
liistory of gastro jojunostomj and the jejunal flooding indicate the cause in
the £iost*openti\e tvpc
Tie lianim meal apjiearancts art al o usuallj quite characteristic As the
stomach fills the hanum pours out into the colon or jejunum and thence
colon Beanng in mind tlie fact that the actual fistulous connection m a
gastro jejuno colic fistula niaj not lie visible and that the jejunum mar fill
terj quid 1^ mthe normal it is evident that with a meal evamination one must
look for an immediate filling of the transverse colon as a proof of the pre«.enoe
of a fistula and in this connection it ahould be remembered that an opaque
meal maa reach the t^lns^crse colon per aias nalurahs m the space of on hour
or lc‘‘S Stress must tliercfore be laid on the immediate colomc fillmg Tin-*
doe^ not always Imppcn In o ca'se ob<«rvcd bj the irriter the colomc filling
was dclajed for an hour It was not until a banum enema was given that the
jircsence of ajiastrojenmo colic fistula was conclusively jiroved Banum m
the stomach after the administration of a banum enema can mean nothing
cl e than a fistulous track between colon and stomach
CiiOLECi sTO oasTPic Tistui^ — Tlie only other internal gastnc fi-jtula
dcsjrv mg of notice is the cliolecjsto gastric It results from the ulceration of a
gall stone through ttie adlicrent walls of the two viscera m question or from
jwrforation of a gastnc ulcer simple or mahgnant Banum emulsion readiU
pas from tlio stomach through the fotnla into the gall bladder and thence inav
pasa into the bilc ducts If the bile ductsarc outlined the nature of the condition
iscloarlv evident If however onh the gall bladder is filJerl it might be niis
taken for a duodenal di\ crticulum of the ncquirevl type A lateral v lew serves
to di'itinguish lietween the two The gall bladder lies antenorU in the
abdomen while n duodenal diverticulum lies on the posterior abdominal wall
CHAPTER
NEOPLASMS 01 THE S10M\CH
BENIGN TUMOURS OF THE STOMACH
Types — riiese are all exceedingly lare Pathologically they fall into three
groups — conncctirc tissue tumours glandular tumours and cysts
CovxECTiNE Ti'5SUe fCMOUns — Fibromata may be either polypoid or
mtnmural more commonly tlie former in the pyloric region ^!^/om(tt^ and
fibro mtjowata form the commonest tyi*c in this group Upwards of sixta
ci«es h ne been reportccl They may bo iiediincnlated either sub«crou? oi
Rubnuicous or intrimural Angiomata and lipomata may aNo occur the
latter tending to form largo mtngastric pedunculated tumours
(Tr^AXTitTLAuTiDrorTis — Under this heading are the Bolitar\ and the mtil
tjple pedunculated adenomata llic eoltfartj adenomata form the commonest
tajic of gastric polypi occur usually m the pyloric region and may reach the
size of an apple
Tilt multiple adenomata (syn multiple mucous polypi gastnc iiolvjiosis)
ate spread uniformly oser the gastru mucosa and rareh reach ft larger
sire than cherne^ Tlioy arc gciiemlly found in conjunction mth chrome
gastritis
CxsTs — Iheso are rare and result from injury degeneration of tumours
implantation of hydatid" or retention cysts in chrome gistntis
The hidatul casts maa rcich large dimensions
Radiographic Appearances — It is unlikely that a subserous pedunculated
tumour could be demonstrated satisfactorily in a radiogram The intra
gastnc poUiioid tumours arc on the other hand readily demonstrable with
careful teclmique
If ike tumour be itngle ai d »maU it wiW ha completely obliterated by filling
the stomach with an opaque cream OnK by employing the mucosal pattern
I'ertViTfirff/i? csf« tffe< tipe Ifo rwiaVA?
If it I e fiingle and large it will show in a mucosal relief picture and visually
produces a filling vlcfect in the filled stomach This filling defect tends to l>o
roiintl and mobile
Multiple jolijpi province charactenstu filling defects — numcroits small
roundcvl gaps in tlio barium shadow scattered throughout the stomach If
these arc not \isible in the fiUevl lower pole of the stomach gentle pressure
jmrlK to omjity the lower jiole of liariom will bring them into mow
The c intragastric benign tumours can be shown witli great clantv by air
80
(a] (6)
Fjo o'* — P c<l incuintetla lonomnofthei wpjlor c rpj!ion of tl (. Btomaoh On screen txammA
<1 n ll o tumour j ro lure 1 a routuled n obilt fill n;, -defect and coul I be d laced thro if,h tl o
pv loruB into 11 o d lodcnum an I back oga n (a) Slwws the tumour in tl o p\ lor c antnin and
(6) m tl «1 uch 1 num
m mnrkctl contract to the di«otgani ed irrcguVaritj of outline of an intmgnstnc
enceplinloid carcinoma
Ajuxta ptjhric pohjpoul tumour maj i»n<»3 tlirougli tlic jijlonts and cause a
roumled luolnle fiUmg-tlefect jn the bulb (Fig 52) A further “tage of the
i>ame process h a gnstni dnotlenal intiis.-jusccptioii
8S ALniEXTARY TRACT
CARCINOMA OF THE STOMACH
Tlie stoiunch is tlie commonest site m the hodv for carcinoma to occur
It IS .1 disease of distressing frequenc^ and the insidious nature of its onset
increises tiie importance of ant method of micstigation that luU lead (o
earlier recognition of the condition Radical treatment is feasible only m the
earlier stage of the disease, and the earliest stages are quite latent clmicalU
Radiologj affords probahlj the most reliable method of demonstrating carci
noma of the stonncli In the advanced case tlie radiographic picture is
Tirtinlly conclusue
In the earU stages the \ raj method is not quite so conclusne as m tlie
later but still it affords the most accurate method at our di-jiosal for the earh
diagnosis of gastric carcinoma and bj the time such a lesion has begun to gi\ e
anj chntcal sjmptoms it is demonstrable bj careful \ ra\ examinatiou
' etiology
' Ace — Carcinoma of the stomach mas Ik? met svith at nnj age but is com
monest hctuccn 40 and CO
Sex — "M en arc afTcctcd more comtnonij than women m a proimrtion of
about 3 to 1
pREsrois ‘sisirLE GA«iTRtc UtetR— Much controserss has ranged round
this question but such authorities as C II Maijo ^loijntkan Sherrtn
and Pfiuchil hold that old gastric ulcer nctise or healed is a definite
(etiological factor
Pathology
Ppmarj carcinoma of the stomach mn\ lie tomjio'cd of either spheroidal
or columnar cfclU Either t^■pe maj undergo colloid degeneration Depending
on the amount of stroma present the growth is dt scribed os ‘ scirrhous , or
medullarj, eneephiloid or fungous
The spheroidal celled tape is twice ns common as the columnar and is the
usual t\i)e of malignant ulcer
Tlie columnar t\{>e is <ommonc«t m the pjloric region frequentU in the
form of a fungoid growth
Either t}j>e ma> infiltrate the whole organ guing n^e to one form of
‘ leather bottle stomach Accoitlmg to iAcrrcii the sjiheroidal celled %ariet\
causes a diminution in the size of the leather bottle stomacii while in the
columnar celled %arictv the gastric lumen is not diminished
Site
In ‘)0 i)or cent the growth is m the pjloric half of the stomach
It IS locitcd on the leaser cur^c in about j»er cent and then in descending
order of frcquenca on the postenor wall the jnlornji the greater cune and
the cardin
NEOPLASMS or THE STOMACH S[)
This distribution is in agreement with the view that gastric ulcer is a pre-
disposing factor, being ^e^J similar to the distribution of the latter
Cancer of the stomach commences in the deeper lajers of the mucosa, and
tends to spread widelj m the submucous layer The induration marks the
limit of the infiltration of the mucosa but the submucou-s infiltration maj
extend for several centimetres bejond TIu-» is of importance in estimating
the operabihti of a growth from the X raj appearances
Radiographic Classification
Prom a radiographic point of mow carcinomata of the stomach fall into
the following categories
Scirrhous Locah«!ed
Diffuse
Encephahid
or Fungoiis
Jlahgnanl Ulcer
Localised Scirrhous Carcinoma
By the term “ localised ’ is meant a growth affectuig portion of the stomach
on!}, m contradistinction to the diffuse tjpc which causes leather bottle
stomach The characteristic X ray feature of this tyTie is a contracture of the
lumen, causing one kind of filling defect
The filling defect oftlus typo ofgrouthnmj' assume a lariecl form, depending
on the site and extent of the growth It may insoKe either curve alone, or
both The narrowuig of the lumen may be slight in extent or extreme It
may involve a comparatively short segment of the gastric lumen, or a Inige
fiortion The transition from healthy to infiltrated stomach may be gradual
or abrupt, so far as the lumen is concenwl As a rule an abrupt stepping
back of the barium shadow occurs at tins point A common ty|)e of filling
defect IS the napkiv rviff defect as though a napkin nng were constricting the
gastric lumen {Tig oSf As wonra' Oe expeti'ea’, r'lie closer to tile pv ibnis, tile
narrower the constriction, and tIio«e at or clo«e to the pylorus commonly cau«e
obstruction
Although these defects are so \aned in shape, they present ccrtsin
coninion features
(1) They remain constant in shape Thcir pirticular configuration must
remain essentially unchanged m a senes of mdiogmms, allowing for slight
variations due to the degree of gastric filbng
(2) Tliey arc a|x;nstaltic The jienstaltie waves can frequently be traced
down to the upper limit of the filling defect, there to disappear
(3) They display a lessened flexibility' when tested by radioscopic
palpation
00
ALniENTARY TRACT
(4) In contradistinction to the cnccphalotd tjx*® thc'-o scirrliotia filling
defects do not tjpicall} present Rn\ ‘spikj oi ja^^ged outline
(o) V palpable thicl emng or mn‘«s ina\ l>e present
In the majority of these cases there is no doubt as to tlie nature of the
condition but\er\ earlj case-^ma\ show no conclusive feature and doubt moj
arise in sonic of the pjloric growths
Inthevera earlv inaUgnant infiltrations the onlj sign ma\ be the pemtal/ic
jump described bj FraenUl and then onU if the infiltration be on the lesser
Fio u3 Ann liar Mrrrhow arr nomo of the | 5 lt>rr ftrtrum jiroiiucing t1
napkin nn I rarnnt%
or greater tunc If on tic posterior wall U would be indetectable radio
logicnlh in the acrj earh stages If on the greater curve it would lie more
obaiou*- beenuse of the mterferenee with porKtalsis
Tiie mucosal relief pattern is considerably altered by a scirrhous infiltration
the nonnal ruga stopping short at the c<Ige of tht lesion
Definite changes in the pj lone function take place in scirrhous cartinoma of
the stomach If the growth be not causing mechanical obstruction the
pylorus tends to be widcK jntent — the gajiug pilonis of cancer In a
IsEOPLilSMS or IHE STOAIACH
91
certain fimnll percentage of ea^ this is due to an infiltration of the pjlc
canal transforming it into an open rigid tube Usually however such
infiltration causes stenosis and tlie commoner tj'pe of gaping pyloms is fu
tional Slid associateil «ith the ach)]ia uhich is the rule m carcinoma of •
stomach in anj situation
Commonlj the contrast meal is seen to pour m a steady stream through i
rigid gastric lumen into t)ie duodenum Tlie hek of peristaltic actintj m
extensno scirrhous growth in no wnj alters this rapid transit Indeed i
— Care noniA of tb<' ( a» >nnl a irolueofj\ hapetl hour confraeturc
more extensive tlie infiltration the more marked is this featme reaching
maximum m the leather bottle stomach
Carcinomvtoos Holr ol\«s Stomach — ^This appearance results vvhei
Rcirrlious carcinoma inv oU es the pars merlia m an annular fashion Chanict
i^ticalli the hour glavs is \ shaped m contradi'stmction to tlie B hour glass
Bimplo ulcerition (Fig 14) In the latter the contracture is so!eI\ at tlie expei
of the greater curve In the \ carcinomatous tviio both oiines are involv
m the contracture the lesser curve to a le^ degree than thegreatei In this tj
ofhour glass thc«tenoccdcommunicatmgchaimel IS iisuall} vi iblemitsentire
and little or no ov erl aug of the upper loculus occurs The isthmus bei
u filling defect shows the characteristics above described
'^ccondarv n* njhageal dilatation 1*5 not uncommon in ca^es of scirrhc
92
\L1MENTAR1 TRACT
circmoma of the stoinnch ^\here con&idenble tlimunition of the gastric lumen
has taken place This dilatation is detcmiined bv the curtailed ga«tric
capacit\ and not On gross obstruction to the gastric cflln\
‘kciBRHOLs CARcrvcnrA ot THE PrLouic RhoroN — In this site the groutli
usually assumes an annular form and eari\ causes obatruction (Fig 00 } Con
siderable difhcultj innj be exiienenced in diflercntiating sucli a legion from
simple cicatricial steno is orthehajiertrophicpjloncstenosisof adults Ifthe
tio — 01 tncC R snnutsr sc rrl oU'< rnr I omn ot tl e 1 vloni*
obstruction be marked it maj be next to impossible to obtain a satisfaetorj
view of tlie hteno ed canal and one nia\ have to bo content w ith tl e demon tra
tion of organic p\ lone c bstrnction C ireful preUininarv preparation directcil
to ensuring that tlic stomacli is quite emptj prior to taking the opaque meal
IS of importance If the stomach already contain transjKireut secretion the
^icTTit(Tft\iTAwri tl? Wic lAtmti ta\ •jnssage is ■nmAeieA ToxitA'i Tfitntr •Aiffit’a’A Ivi
carcinoma the stenosed jms«ia^e is ns a rule longer and more irregular than in
simple stenosis The differential diagnosis Ijctucen it and hypertrophic
stenosis of adults is discussed in the section on the latter condition
Diffuse Scirrhous Carcinoma
J Jiis gives rise to one form of leatl er I nttle ptoninch or Imitis plastica
Tilt striking feature is the diminution in the hzo ot the stomachy It presents
NEOPL\*^MS OF THE STOMACH
93
ftn npijcannce similar to in exaggerated hvpertonus tapcnng npullj from the
fundus to the pjlorus Tlie stomach h more or Jc'ss horizontally disjiosed
ajicnstaltJc in the mam and rapulK emptying Its contours uill as a rule
show mild jrregulantjcs and the^i persist in succeeding radiograms In other
nortls there is a circmomitous filling defect pre^nt but ';o exten«i'e as to
m\ ol\ e \ irtuallj the entire gastric contour (Fig of) In these cases again the
dimiiushed capaettj commonlj results m asophigeal dilatation a point which \
F C C Sc rrho w larc noma of efotnarh leutJ er I Ottio t •po
distinguishes them from total gastrospasni (Fig o7) In gastrospasm the
contour i-. more regular and gastnc cxncwntion less rapid
Carcinomatous hnitis plastieo shows a lessened flexibihti to radioscop c
palpation and a tendeucs to fixation in its position just as does the localised
scirrhous lesion
The «imple and st plnlitic forms of ge»cmh'«d Imitis jilastiea are identical in
their radiographic np]x.arances to those described abose and cannot lie
dinbrtntiatcd rodiologiialls from the malignant tape
Medullar), Encephaloid or Fungous Caranoma
In this tape of neoplasm the filling defect the cardinal \ raa diagno tic
feature assumes a different taiw from that of thevcirrhous growth Considera
tion of the niacroscopit morliid anatoma will indicate the difference In the
04
ALIMENTAR\ TRACT
fimgOTis tj-pe then, is tn addition to the mucous and submucous lufiUiation the
formation of irregular tumour masses uliicli project into the gastric lumen
Again ulceration maj take plate m these tumour masses further to compheato
tlie picture In addition therefore to the irregulantv caused hj the infiltra
Flo ~ I) a iHP M-irrl o >!i (tiirinon II of tl e> Hi nicl nr n at gnniit I ntli(*r bottl etoinnrh
turn of the gnatnc wall similar to hut mort irregular than that ot a scirrlintis
infiltratwii there uill W gaps in the barium shaclou due to tJie projection
of the tumour mas-^s into the lumen of the stomach These added dtfects are
not iiiapth called fm^cr imnt defects as thei are often roundeil or oral
and discrete not unlike finger print imiiressions {Figs "iS ami SO) Tlie true
ALIMENTARY TRACT
{III
tiG W) — Frw efhaloKl CAMnoinn of Ihe nWiiiA shon
itiji Uii* rrliof
fingei print nppcamnro docs
not alwajft obtain Innianv
ca-jcs there is meielv a hrge
irregular gip m the banum
shadow, often \ntli sjiikj,
jagged edges Tlie'-c fungoiLs
filling-tleleets should be
rca‘*onablj constant in a
wies of radjogratiis, allowing
for variation in the amount
of opaque cream in the
stomach Thoac on the con
tour of the gastric shadow
show least change those
inside the gastric contour,
due it> Uiyy>o»r oj>
tlic anterior or posterior wall
maj %arj conbidernblj
according to how much the
stomach is distended with
the opacpio cream The
otlicr radiQgranlue aig iUi.
na mely tiie tocnJ anenitalBiSj
tlie rapid emntMng the
gaping pvlonis. tlie les sened
fl^Tb ili^ and inohiiitv.^o f
the "gastric walL. ai^ all
iTppucnt in tfiistjqie as in
the Btirrhous Th e presenj a?
o f a palpable epigastric mass
l alnore common in this ty^
tlian in n scirrhous ^ut itis
a lat e i(.atunMn~Ij^| u. Xht *
Tc^M^iagcal dilatation and \
luiu r glass do not' t>T) n^ftHt
occur^
1 Jie niiieosal rehefpattem
in fungous carcinoma shows a
marked and abrujit altera
tion of the regular pattern
into a tompleteli irregular
one in tlie 7one involved bv
the tumour Thwdestnicfion
NEOPL \S'\IS OP THE STOMACH
97
of tile normal configuration more marked than in tlie Kcirriioua tj'j)©
(Fig ro)
Fungous Carcinoma in Special Sites
(1) Antfuior or Posterior Wau*— A n eirlv papillomatons grondh on
tlie anterior or posterior nail maj easily be rendered niMSible bj too complete
filling of the stomadi mth barium cream It is important therefore to stiidj
the Rtomacli Mhcn it contains a small amount of banum onlv ^\hen there is
more chance of such small growths being \nsible in the mucosal rehef pattern
(2) Fcndis — Carcinoma of the fundus is usually of the enccplnloid type
J-.i ii Jj-An(uon«ianrjUi*^>Jnnr man man J tp^pjf'uni* J'jt ly, ^vinr^
H\i. bS slxrte (be bar um
and produces a filling-defect similar to el'^where It is best demonstrated in
the eiipvno position
1 he majont \ of grow ths w Inch in\ ol\ e the canlia are primarily asophagcal
and hn\c spread to the stomach round the cardia Obstruction there is the
ni!e and radiographically a narrowed tortuous track is seen
PiffAio has cnnmemted the signs of a fundal neoplasm as follows (Fig 01)
The gns (nibble ma\ show the tumour in relief contour Again tlie dia
phragm outlined bv lunc alrore and gas in the fundus below may bcnndulv
thick Tlie tumour adds its quota to the thickness of this shadow
\ r n~7
9S
AI.BIEN'TARY TRACT
Th^jiUiug oj Ihe/undus b\ a banum
cream nia\ be abnormal as the cream
poure from the cardia it may trich/e
irregularly over the tumour mas»
The. mucosal palfern is interrupted
by the tumour mass
FinaJhj the filled fundus shows a
filling defect
(3) PiLopic Antrum — Here ob
fitruction frequently suiicrv enes but
the cause is more readily demonstrate<l
radiogtapliically than in the scirrhous
tvpe the jagged irregularity of the
stenosed passage as a rule makes the
diagno IS easy (Figs 62 and 63)
Carcinomatous Ulcer
Carcinoma developing in the edge
of a Bjinple peptic ulcer cannot bo
detected in the early stages
In a single examination «overRl
features vv^ll suggest that the ulcer has
undergone mahgnant degeneration
such as large suie of the ulcer crater
An ulcer crater with a diameter of 1 inch
or more should raise the suspicion of
malignanc\ \g'im the presence of a
filling-vlefect immediately adjaiont to
the enter should ni=e suspicion Care
must be taken not to mistake the gap
coiiscrl by mucosal cedema for a cir
cinomatous filhng-defect Occasionallv
some thickening may lie evident on
radioscopic pilpation
KtrUin lias empliasiscd by the
adoption of the term meniscus m
r n SIBCP" n tl e I Ncfopmeit of «
rare i oinn of iho p lorte antnim (a) l-afl'
Mtam (A) f o irmontf « (e) Tentnonli
lat^r Tlic condjlion wiw In nfH*sl nut o-
"allv at the frst ^nionunation but
pat et I fT-r I**'! OJ oral o
KEOPLASJIS OF THE ST05IACH
00
appearance seen in many malignant ulcers of aikI near the lesser cune Tlie
meniscus appearance consists m a translucent zone, I or 2 mm m width,
separating the banum filled crater from the mim barium raas'^ filling the
gastric lumen (Fig 04) He states that this is due to the growmg malignant
edge of the ulcer It is an apjiearancc wluch should raise the suspicion of
tio fil — MaliunPint 111 cr Ji Rh «j> on llw los-er ciir%e wlifawiug t1i& jnemsoiw effttt
malignancj, but the writer hasobscractlit in seseral ca^esiiUimatelj pro\ed to
bo innocent In llic'^e the marginal cedemn was the caii'c of the meniscus
If the case be imtlcr repeated radiological ob^eiwation during medical
treatment, failure on the part of the mucosal mdema to subside, and of the
crater to sbrmk, would also ruse the probabihtj of malignancy . It should bo
cmphaM^cd that many of these malignant ulcers are \erv slow growing and
100
ALIMENTARY TRACT
that the gastric acidit j ma\ lie normal Exploration sliould be undertaken if
there is anj doubt, since these mahgnant ulcers are more amenable to surgical
remo\ al than most gastric caremomatn
Tlie folloinng t ihle, adapted from Kirkhn, indicates the mam difierential
radiographic features in simple and malignant gastric ulcer
SiMFLt
Jtm or less
SHArv Ilcmiypl rnrttl an I fiharpl> <l^med
U><uall> OR Ira.-v'r rur\«>
from p>Iom4
BrovE
I’eristalsis
IhUJKCS
TiSDEBsrs't
TnpRAMxnc Tr^r
Comrrgr Lorons Anal halo tf
fm jf <n f<tfc
Tpnd« lo bt> &rli\c
SpA^tif jf an\ chancr from ilic
normal
rresent
HroU
LHUaflv more than 2 $ cm
Conical or irr^ular poorh <lcfincd
Menwcu'? effect common
a Aruble »jte but most commonlc
on lesHtr cune tow*nl< ] >Ioru'J
Ttiose on the gre/itcr curve are
alvrttjb fnalizncuit
Interrupted without converpenoe
Often iliiO'&i-'lietl or absent
Tend'i to gape
Absent
Fnlargnt or rimauvA «ts(ionan for
ft time
SARCOMA OF THE STOMACH
Sarcoma, it is said, accounts for 1 per cent of all gastnc tumours It is
virtually ne^er diagnosed radiographically so closcK does it simulate cam
noma m a mdiograni
Clinical Features — The ago incidence for sarcoma of the stomach is rather
earher than that of carcinoma Iteginning at 20-30, and occurring icn rarel)
after 70 There maj he few or no symptoms Vomiting occurs in about half
of the cases A palpable epigastric tumour is common , more so than m
carcinoma Hypochlorhydnaandachlor/ydna ma^ occur hut less frequenth
than in carcinoma IlTmorrhage and perforation maj take phee P\Ionc
stenosis 18 rare, and cachexia a late symptom Kundrals sign — swelling of
the hTnph nodes at the base of the tongue — in the presence of a palpable
cpigi«tnc tumour is indicative of a I^mphosarcoina
Site of the Tumour — In collecleil cases the tbstnbution was as follows
greater curve 18 pjlonis 14, lesser curve 1 anterior wall 8 posterior wall 8
difTiiso infiltration 4 cnrdia 1
Three types occur and eich tends to present a dtHbrent radiognphic
picture
(1) Round CEU to Sapcoma — ^T lns Iwgins in the submucou-s tissue,
and ma> l>e diffuse or locah«cd furmmg a tumour maivs which encroaches on
thegsstnclunien Tliistv^pe most common in the pjJonc half of thcstomatch
13 usually mistaken for an cnctphaloid carcinoma or polj'poid growth It
forms CO per cent of gastnc sarcomata
(2) briNDLE CEixED .‘'AFCoMA — ^This the next commonest tjjio (30 per
cent ), tends to form a peduncahted aobseroiis mass It ma> become large
NE0PLAS5IS OF THE ST03IACH
101
enough to fill the abdomen, and be mistaken for an o\amn tumour Cjstic
degeneration is liable to occur In a bitmm meal tins tj'pc cause a local
gastric deformity of the intrinsic type, and possible, a considerable general
deformity and displacement from extrinsic pressure
(3) M MPHoSAnco3iA (S>f» malignant Ijanphoma) — ^These tumours
tend to infiltrate the stomach u ideli , and to protluce diffused thickening of its
uall Other portions of the ahmentarj canal, such as the ileum and caecum,
arc frcqucntlj simultaneously involved Tlie pyloric antrum is a favourite
site, but the pylorus itself is not usually implicated, and obstniction is
uncommon The growth may show nodular or polypoid excrescences
Radiological Features — ^These are very varied as may be gathered from
the macro‘’copic pathology Spitzenberffer has recorded a large nodular
lymphosarcoma springing from the fiindiw and infiltrating spleen, diaphragm,
and cardra Patlison recortls six cases and states that ulceration is rare
One of Ins cases presented a mche deformity, while the others siiniihted
carcinoma The radiographic features are those of fillmg defect, rigidity of
the gastnc wall and apenstalsis, but there ,ja^othmg in those features vihich
serves to distinguish the lesion from‘flE'‘earcmoma, for which condition it is
nearly always mistaken Cowrtney Gage has recently desenbed vihat ho
considers to bo a characteristic appearance m tbo submucous pedunculated
myosarcomas of the stomach These tend to necrose at their centre and
produce a filling*defeet like a tangerine in the middle of which is a deep
ulcer niche ' Odqiist has re[Kirte<l an exactly similar appearance m neunnomo
of the stomach, a rare, usually benign tumour, poorly vascuhnsed and
tending to necrosis It is most commonly found on the greater curve
CHAPTER I\
^ AIISCELLANEOUS GA&fRIC CONDITIONS
CONGENITAL HYPERTROPHIC STENOSIS OF THE PYLORUS
AiTitorau thl liistorj anti clinical triad — propiilane vomiting visible jvri
stal'<is and palpiblc tumour — on nhich tlie diagnosis of this condition rests are
so chaiactcnstic ns to leave little doubt as to its nature \ raj ewminatifn
forms a valuable check and liec-omcs of piiinc importance when tint trnd is
not complete
iEtiology — Two vnews are licid as to the cause of this condition that tlio
hypertrophj isaprunarj congenital overgrowth of muscle alternativclj tliat
reflex spasm is the cause of the Iijpertrophj It is n true hjpcrtrophj' of
the cinular fibre of the pjlonc canal fho hjiicrtrophj stops al ruptlj
nt tlie duodenum but extends to some extent info the prcpjloric portion
of the stomach emerging gradually into the normal 'Males are affected
more commnnlj than females m a preponderance of 4 to 1
Technique — ^llio babes alTected arc til wasted and enfeebled and all
manipulation should be reduced to a inimmuin Especinllj should thoj bo
protected against cold during the examination Iho meal should consist of
2 3 oz of ivanii thin sweetened Imriiim emulsion or a similar amount of
warm milk containing barium This can nsuallj bo given m a feeding bottle
hut if this IS not effective the meal must be given through a catheter Ihc
child 13 tlicn laid on the \ raj couch intcnmttcntlv screened for a short jioriod
to studj the pjloric function and radiograms taken everj lialfhour until
the stomach is emptj Note must Ire kept of anj vomiting during the
period of examination
Radiological Features — Dio appearancxoi in the stomach after a contrast
meal lias been given depend on the duration of the condition
In verj joung infuits there is little dilatation and perLstalsis is active
TiVit; vign at-truiv’oTig to Mmw'mm ftwd ys* ti V.'ngVViWievt •f/j’iC/iWi
canal with sharp difTcrciitiatiou from the pjlonc antnim As little passes
throUe,h the pjlorus and at infrequent intervals demonstration of this verj
valuable sign is diiTicult ami mav Ire imjKissihlc M hen seen the canal is
not onlj lengthened hut cxtrcmelj narrow no more than the thitkms.s of a
needle Bj careful pdpation it mav Ire possible to dotermine the comcidencc
of the pvlont tumour with tlie p>lonc tnd of the stomach or the jivloric canal
if visualised
Ihe time of gastric evacuation is usudlv greatlv lcnj,thened Compared
^IISCLLL4^^0US GASTRIC CONT)ITXO\S
103
\Mth the normal emptying rate of one to tMO hours the stomach ma> take four
hours or more to cAacunte its contents coinpletclj sanation in tlui
may result from vomiting This must be alloucd for in nttemptmg to
estimate the severilj of the stenosis from the degree of stasis According
to iS/roMS? if less than 70 per cent of the meal has passed out of the
stomach in four hours the seventj of the stenosis is such as to call for
operative interference
If the condition has lasted for a month or t«o dilatation becomes evident
11 lUi describes the \ rny features at this stage as being dilatation of the
stomacli deep hvelj peristalsis and well marked stasis in addition to the
stenosed passage The deep wide penstalsLs is most marked immediatelj after
taking the opaque cream and tins is succce<led after avanable interval by atony
In the 1 ite stages tJie initial bypcrjierist iJsi& is less marked and of bnefer
duration vihile the atonic dilatation increases
CHRONIC HYPERTROPHIC STENOSIS OF THE PYLORUS IN ADULTS
f JJ 3 ainiwy has given a full descnption of this condition from whicJi
pajKf the following account laigcly taken The abnoninlity is a rare one
In the 'Mavo Clinic eightv one cases were found
// in 00 000 examinations Titimva records /""N.
If , \\ three cases / \
jl }j Morbid Anatomy — ^Thc essential feature is / \
VwA^^/ antnim pylon This )l
the p> lone splimctcr ^ -.i
/^J is not involved to any great extent although ^ f
d ma\ show some degree of liyqiertropUy also j
causation is unknown ? *
'w/ Radiological Features — consideration of \
the morbid anatomv will indicate the nature of
'y tiic deformity winch this condition produces
Y ,c 65 —1 111 the barium filled pylono antnim Iig Oj
D totionnl lull represents a longitudinal section through the
r Ion rinai pjionc region and Fig OC shows the cardinal
1 \ntml 1 tmtn ° . Ine n Injer
4 p\forcPihnc appcnmnces in n banum mcai examination as *tOTo«i
icr follows of ti p i %lorui in
troplielpr<' (1) TlIF PyLOBIC liftRIXSlOV — Thc tniC Jr or
* f pyloric spliincter usually slightiv hy pertro ^
pined indents the base of the duodenal bulb
This effect \ ancs mth the irosturc and procure on the abdomen It mav
disappear in the erect poMtion
(2) Int. rnEiiLORic Gi-fit — IJ m is a diar|> banum protnision into a
mucosal cleft lietnecii the true sjihinctcr and the hypcrtropliicd prepvJoric
Fn 0"— Clron )i\{ ortn3{ I >iofil pp\|)ruiiniina<l lit Ftninl iap»n
of It I c»<ti n wr fp IS in> u1 1 asmcialmi «itli »»m >1 om-wM p\ si OMe<f B h\i prtroph r
e] shtl\ ] al| nbl col trnctili’ j tri >ton a-gnrat Cii»<inc res li c iit >1 m>
fibres It mn^ lie mistaken for on ulcer mche but cla&.simll 3 njiiwars on
both sides of the j)\lon(. lumen
(3) Tin ■\vrnAL LnMtv — Tins is considenibl^ inrrouod in its distal
portion § of an incli or less The length of the inrroweil jmrtion is from
AnSCELLA^LOUS GASTRIC CO\DiriO\S
105
1 to 2 indies It \anes m eihbre from time to time In spite of this it ne\er
relaxes to any extent
(4) Ihf Proximal End of the Stfnosed Passaof is Round in contra
distinction to that in a scirrhous carcinoma which tends to he jagged
(5) AIucosal Pattfun — In the contracted canal the mucosal folds arc fine
and sliallow At the proNimal entrance they are contorted and ma> hold
barium rests tenaciously
Differential Diagnosis — ^These cases are nearly al\\a\s mistaken for annular
scirrhous caicmomatn Twining diagnosed one of his three ca'ses corrcctlj
In considering the differential diagnosis the following points should be borne
in mind In this condition the canal shows eontractihtj and fine mucosal
folds There is no pj lone flooding or palpable tumour The antral extremity
of the filling defect is smooth and rounded ^Pig G7)
GASTRIC DIVERTICULA
T\no tjpos are described congenital and acquired Congenital Di\crticula
occur ns a rule on the lesser curve near to the cardia Rarelj they are lower
down on the lesser curve konj^t-’ny has recorded one arising from the middle
of the greater cune The^ consist of a mucosal protrusion between the folds
of the gastro hepatic omentum In size they a ar} from that of a green pea to
a clierrj Cases have been reported m detail by and Bngg$ L II
Paid has recorded six cases and states that the commonest site is on the
jiosterior wall at the level of the cardia Those m this position are best
demonstrated with tlie patient supine and rotated slightly to the left
R iDioLoorcAL Features — If seen m profile the) present a rounded
regular outline with a neck of rarjang width and length Thej fill readilj
during a barium meal examination and if examined in the erect position tend
to show double barium fluid and air levels (Pig 08) The diagnostic problem
1 % to distinguish them from deep ulcer craters Several points are of importance
m tins connection such as their regular rounded contours and the absence of
reflex spastic phenomena gastritis tenderness or local cpcicma of the mucosa
around the neck of the diverticulum Careful estimation of the actual distance
of the diNcrticulum from the line of the lesser curve maj help In diverticulum
it IS appreciable and real in ulcer it is onl) apparent If the muco‘-dl
atlciim be discounted the base of an ulcer crater is seen to be intri and not
extra mural ''tasrs tends to occur m diverticula and bnnum maj he “cen m
tlicm long after the stomach is emptj
Astuilj of the mucosal relief piltcm maj be informative The classic ap
pcarancc of the nigic round an ulcer dcsenlietl under that section wall be absent
It ma) bo possible to trace the mucosal folds nght into the diverticulum
Acquired Diverticula — ^Tlicso are small tent like protrusions of tlie gastric
wulj resulting from the drag of adhesions Tlie) areverv rare usually fccen in
connection wath gastne ulceration and arc usunllj mistaken for ulcer craters
100
ALDIEXTARY TRACT
FOREIGN BODIES IN THE ALIMENTARY CANAL
Opnque foreign bodies arc iiistintly recognisable in a radiogram Trans-
parent ones can lie demonstrated oiilj if tliej are of sufficient size to cause a
filling-defect in a Innum meal
Opaque Foreign Bodies
Oftheiunnj tj pcs of foreign bodies nlutb miv be found tbe following are
common pins safetj pins linirpins nce<lles nails taclvs coins, buttons etc
l ft os — (.a'trir ditt-rlituiiiin lii^h t»p «B Ibe
osUusn ««<n end oi
treune (<») I'o'tero ontenor ' ie» note tlw*
(»> OW«iwoNn\i
Rounded objects such n> <mns and buttons, ustnll^ pass Irreguiir
objects sucli as tooth plates gi\e more tnmble and mnj liecome impncted
Xnils and tacks pass as a rule but pins and needles t'lwcialK the htter
prc'cnt a problem radiogniph»call\ and thenipcuti(all>, from their tencUnc\
to j>enetrate the m«cus in which thej lie
Trciivioirn — In e\er.\ cast m which it is suspected that a foreign bodj has
l>ecn swallowed the pharynx ONoplmgus, bronchi and the whole abdomen
and peUis shouhl l>e c-irefullj tuirycycfd lluoroscopicallj and radiographically
Screen examination is not enough If that alone bo ii'cd, the most dangerous
tj^K* of foreign bofh — a pm or needle — maj l»e overlooked Tlie foreign liody
AIISCELL\KEOUS GASTRIC COIsDlTmS
107
l«?cn Jocated its subiequent career should be ob ervetl m didj radio
gmnis until it is passed The stomach forms a common halting place
Once past the pjlorus the terminal ileum is the next then the CTCum
and subsequently it may be found anvuhere along the colon The gas nor
jjialh present m the alimentary canal is usually tnoiigli to onentate the
foreign hodi hut failing this an opaque meal mas be giien
Transparent Foreign Bodies
Bodies sucli as fragments of bone pencils or bezoars require examination
Mith a barium cream If the foreign body be large it ma\ cause a filling
defect when the stomach is filled with banum emulsion '^^ore coramonh
such a procedure would blot the foreign bod\ out in the picture Small
opaque bodies can occasionally be outlined if one mouthful only of the opaque
oinubion be g»en and the gastric inuco*-! outimed The foreign boch may be
voated at the same time and its outlines so made visible
rniciioBFZo\P — A h ur ball in the stomacli is a rare occurrence caen rarer
than before liccnuse of the modem fashion of short hair among women The
fci70 m ly he considenible — up to an almost complete cast of the stomach
B\moLOOiCAr r&vTtiRis — A large one may bo aisible through gas m the
fundus The upper end may lie seen projecting into the gas bubble — an
npjicaniiK'O winch is quite characteristic If a banum meal be given the
hair ball will become coated with banum and so be Msible On filling the
stomach completely wath banum cream the hair Uall forms a filhng-defect
which if large can hardh be IUI^takcn for nnvthing el^e Finally after the
Innum cream has passetl out of the stomach the surface of the hair ball wall
bo impregnated with banum and again «how a \ery characteristic mottled
blotched ajipearance
I’i.iisiM3iox Be7o in — Ijjis bezoar is found occasionally m •Vmenca It is
formed by the accumulated fibres of the peroimmon fniit and forms a fibre
ball with \ my clmracten«(ics similar to those of the tncliobozoar
fur Dcodexal Tdbi. represents a foreign body intentionally introduced
AwO 4\\v“ .wAxpse A\pj= iic zvWyA^wJ .wJ.vcgva?jW.W9.U/ TAm? fidve iir
terminal oU\e is clearly visible m a rodiogram The olive is proved to lie m
the duodenum when the tulie itself presents n regular reversed & curve The
lower limit of the b represents the curve of tlie duodenum
AscviiiDbs > — Dillenscfjrr lias recorded n case in winch an Ascans lumbn
coulcs was demonstrated radiographicallv m the ileum being rendered visible
bv impregnation with banum sulphate after the pa'wagt of a banum meal
DEFORMITY OF THE STOMACH FROM THE PRESSURE OF
NEIGHBOURING ORGANS
Such an occurTcncc must always lie Ixime in mmd when txmfronted w itli a
gros« dcformitv of the stomach The organs which most commonly act m tlU'-
lOS
\LBIENT ARY 1 R ACT
aretheh\cr spleen p-incrcas left kidnej, and colon Abdominal tumoupi
and marked scoliosis maa aKo produce defomutv of the gastric contour
These pressure defonnitics are mfimtel> variable, depending on tlie organ
responsible
Lt\et — nlargement of the bver ilispJaeea the stomach down%\aTils and to
the left, and tends to produce a flattening of its lesser cune and a displace
ment of the pj lone region behind the stomach
(Fjga 09 and 70) In these cases rotation of
the imtient into the right oblique view la
necessary to \ieu the pjlonis and hulh
Spleen — The gastne fundus and greater
<.ur\e arc tompre^sed and displaced to the
nght in moderate enlargement of this organ
In extreme tnlargcinent the whole stomach
is di'.plaeed to the nght The spleen in a
ea«o of perisplenitis ma\ adhere to the ga^tne
fundus and produce a ngid flattening of its
left contour
Fio «!i_D, pl.c™™t of Up Pancreas —Carcinoma of the head of the
ctomach to the left nn ctilarsc 1 , , , . a a i -
pancreas produces a characteristic stretclmig
of the pjlonc region and duodenal circle
The duodenal arc may bo considcrabh widened and its lumen reduced to a
streak The jij lone antrum and pvlorus maj share in this proce«a and at the
sime time be displaced upnards
Carcinoma or other tumour of the bodv of the pinerens tends to cause an
ettnn<uc central or marginal filling defect in the both of the stomach near its
isthmus In the erect position the gastric lumen is compamtiveh flattened
from before backwards at the lead of the pancreatic shelf and a tumour mass
projecting forwards readiU presses the jioolerior gastric wall forwanU against
the anterior The filling defcit so producetl is tx'picall^ exogastne It has
no clear cut margins and la rcadilv made to disappear mdioecopicalh h'
palpatorx iressurc on the lower pole of the stomach A lateral xiew may
show the actual forwarxl projection of the tumour Twining s method — a
lateral radiogram taken of the bxniim filleil stomach with the jiatient Iving
supine — IS the best method of showing this
Left Kidne) — Onij if it is grossly enlarged does the kidiicj displace the
stomncli The displacement is forwards upwinls and to the nght (Fig 70)
riic right kidnc\ if ^erj 1 irgc max displace the atomach to the left (Fig 71)
The Pregnant Uterus, large Ovarian C>st5, and other hiT'c nbdommal
tumours tend to mi-e flatten and rotate the stonnch so that its greater curve
looks forwards (hig 72)
Gross Scoliosis, with the eoncavitx in the left dorsal region as in the dn
grain causes elevation of the left dome and billoomng of the fundus (I ig 73)
J in 7« Dcfani
no
alijiemar\ tract
Colon — ^The po«ition
of tlie transverse colon
and splenic flesuro tela
tive to the stomach and
their mesentcno attach
mcnts account for the
various gastric de
formities uhich follow
gaseous distension and
displacement of the
former The c deformi
ties are \erj varied and
range from mild indenta
tion to complete voh ulus
of the stomach The
milder changes are asso
ciated with simple
colonic gaseous disten
sion tlie more severe
avith distension phis dis
placement
SurTLE IVDFNTATION
Iio 71 —D I locemcnt of t) 0 ftomaol to the left b> a lor^e FROM CoLONlC BaLLOOV
nj.u h\<iponpphro.w — The commonest
are tliose produced t n tl e
greater ctirao of the stomach gas distentlcd linustrol pouches Almost as
common are the indentations of tlie fundus from distension of tho splenic
lleMire As tho flexure distends it fights v> to speak, uith the gastric fundus
MISCELLANEOUS GASTRIC C0^DIT10^S
in
for posvession of the left cupola of the diaphragm if it succeeds the g'lstnc
fundus becomes small compres'«ed and displaced do\mu ards to tlio midlme
Increasing distension of the flcKurc commonly implicates the distal portion
of the transvcrve colon and
this maj iiroducc an appear
ance of hilocuHtion of the
stomach This biloculation
if marked maj simulate a
cascade stomach but differs
from the true physiological
typo m tint the loii cr loculus
IS displaced to the midlme
(Eig 74)
DciORjnTILS ASSOClATl D
\MTll DISTi*^StO^ AND DlS>
rr«\CEMbNT 01 THE Colon —
A ciiaractcrist ic disphccmcnt
IS that in uluch the trans
sorse colon travels upwards
in front of the stomach and
not uncommonly still farther
upwards between the an
tenor surface of tlio hcer and
the diaphragm the so called falciform colon or anterior hepato dnpliragmatio
inter position M hen this occurs the ^atcr curve of the stomach is dragged
upvrards hy the transverse mesocolon m
front of the lesser curve an<l lies at an
upper level Tins constitutes the so called
ioliuJu9 oj Ote stomach on tts cardio pjlonc
ax%3 (Figs 75 and 70) TJie lesser curve
niul pylorus remain in ajiprovimately their
nonnnl positions Again the liepatic
flexure and proximal transverse colon may
distort the stomach by passing up belund
the liver to tho right of the coronarv
ligament — a jxistcnor hepatonhaphragma
tic inter position
It IS convenient to mention hero the
other forms of gastric aolvulus which can occur One an acute, i jpe
is associated wath a'.ophngcal obstniction from torsion of tho fundus
Another the vohtilwi on lit /ransicroe axis presents a striking \ ray picture
(ligs 77 and 78) In this variety tho stomach folds itself on a coronal axis
and tho antrum swing upwanls m front of the body of the stomach to reach
112
ALI’\IENTAR\ TRACT
tlio left cupola near the canlia
Antnnn and fundus thus lie
close together the former in
front From it the pjlonis
points dosvn'irards to tl eleft of
the spine The condition is
best examined erect m the
postero antenor left oblique
and lateral views Tm o barium
fluid 1e\eU are evident in
fundus and antrum and two
corresponding air poc! ets
This X olviilus can take place
onl> if the duodenum is long
and has lax attacl ments or an
actual mesenten The atiologj
IS unknov n In the case of the
author 8 shown in Fig 77 there
Ind been present a large ulcer
of the lesser curve nearh
healed at the time ofexamma
tion The actual volTulusxms
accompanied b> x erj severe
epigastnc pain radiating back
between the shoulders The
essential feature of all tlio above
gastric deformities due to the
colon Is their evanescent
q lahtj
PATHOLOGICAL AERO
PHAGY
The BM allowing of exccssnc
quantities of airisa habit winch
toA.^ be iL.stms'imt to tbe pa
tient and still more to Ins or her
companions There are two
tyjies
Fm 7 — Atiort XolTlu^ofllc
Btomach on Is tran*! rrsf' fts •* end
leK.*«-rcur><- I rr R loir Samocas'’
re pxnminol on ih rollow ng Unj
uliow nv tl «* \oK'ulu« rwl oil
I,nSCELLAJ.KOTJS GASTRIC COKBinONS
113
ol «lu- of t'
t troa
;„ lU mmpkr Kjpt -or «
S;s““VVe’leftrme' .nd
r:rja icimg or
r "uon' aToo^^ "“‘i^t-Cton
of via the mtestmcs and ‘^a ten
"“‘rlf .^'““re type IS found o>no«> JJ W«uu» \
neuroLo uomen and .a uBuallj accompUs ^
With much noise and fuss A
of air .3 noisily sualloued -nd jhst^ the
gastno fundus It ts soon g _,-ction
lielchma At times the intake and ej
of the L IS so rapid that it has This is often repei ed
reach the rtomach-tho so called be,„^^our of
a nunrher of tunes m rapid , „„,ure
patient leaves no doul.t as to its hjstencal
BORBORYCM Itive disposition
llusmaa he an emhamssmg coniplamt to j
The casual niinhle maj occur „T,e follous the top."to>
l‘marritthe‘XVvure.sffl«^^^^^^^^
X ra> eaanunation may give an mdioa portion
agm, occur m a particular case by revc
rumination or MERYCl sometimes
hcretoao%‘ca"dS^^^^^^
In this ease food could be hroUc ■ppe net u as quite dllTcivn ,
;i:.\:;“™ira:ru™
mhex appeared to be allied to
tion of the phenomenon of ^'ate
X K ti— S
CHAPTER X
THE ^OR’\IAL DUODEXUAI
ANATOMY
Tiin tlie hliort(*st ^\ldest nnd most 6\ed portion of tlie sinsll
intes>tme extends from the pjlonis to tlie diiodeno jejun'il flexure It n
about twelve fmgerbreadths (10 inches) in length — hciire its name~ancl
describes a Iiorscshoc curve It is arbitrarily divided for descriptive pui^poses
into four parts — supenor descending tiaiisverse and ascending Its course
IS as follows rrcuu the p>lonw the supenor portion passes upwards back
wards and uaimllj with an inclination to the right beneath the quadrate lobe
of the liver to the neck of the gall bladder
It then bends shnriilj downwards into the descending portion along the
right margin of the head of the jiancrcas to about the level of the upper border
of the bod^ of the fourth lumbar vertebra
It now lends to the left across the vertebral column forming the trans
verso portion tlien upwards on the left side, of the vertebral column as the
ascending portion and terminates at the duodeno jejunal flexure at the level of
tho seconcl lumbar vertebra
Certain anatomical alationships art of clmical and radiological importance
riRsT or Si n mop Portion — Tlus is variable m position iiichiiation and
level possessing ns it does a short me entcry at its pyloric end Its long axis
depends on tho tv|)e of stomach In the h^qiertonic tjpe it tends to run
6«c/imrrffl to the right and slij^htlv upwards In the hvjiotomc tjpe it runs
upuxirds backwards and with s(»mctiine8 a slight inclination to the left
Above it IS tilt quadnito iobe of the liver The gallbladder lies in doe
apposition to its iqqier and nglit surfaie The head and nock of the }wnt.reas
he lielou It and behiml it are the gastro-duodcnnl nrterj the coiimioii bile
duct and tho jiortal vein riiu* jiortion of the duodenum is coinpletelv covered
bj jientoiicum except lur a small triangular area pwtenorh near tbo neck of
the gall bladder At this area the common bile vhict mnv occnstomllv iiuleiit
the bulli and i atisc a v crticnl bncnr tilling deftet w hen compression is u c d
Tnr Stroxn on BtscFNPiNO Portion is covered bj pcntoucuin m front
onlj above and below the tmnsveme colon Its most imiiortant rclationsl qw
are the head of the pancreas thcduetof^^l^sung and tbo roinmon bile duct all
on the inner side The two latter trover*© the duodetnl wall obliquely ami
ojien together into the niiipulla of \atcr on the medial wall about the middle of
this portion
THE NORAfAL DUODEXUSI
115
Tjif Tinni) on TjiA^^^NEnsE Portion cunes across the spme, great vessels
niicl diaphragmatic crura to the left of the \crtebral column It is conca\ e up
wards It is covered anteriorly bj peritoneum except near tlie midlinc, ■where
it IS crossed by the superior mescntenc vessels Above it lies the head of
the pancreas
The rouRTU or Ascpndtvo Portiox ascends on the left of the aorta for
about an inch or so and then terminates at the level of the second lumbar
V ertebra bj turning abruptl} foniartls nml doirau ards to become the jejunum
It IS covered vntii jicntoneum anteriorlj, and is supported at the flexure by
the musculus buspensonus duodeni of Treitz
Sucli are the classic anatomical position and relationships of the duodenum
Radiologj proves them to be more vanablc than prevnously supposed, parti-
cularlv the first and second portions
Tlie imjjortant clinical relationships are those of the first portion of tlio
•stomach and gall bladder the second portion to tlic bile duct, the third portion
to the sujiermr mesenteric vessels and the whole duodenal curve to the pan
crcatic held, which it encircles almost completely
Structure — The duodenum possesses an mcomplete serous coat and com
plcto longitucbnal and circular muscular layci^ Tlie mucova vanes according
to the part of the duodenum The firet 2 inches—that portion which forms
the duodenal bulb or caji — is devoid of valvulai coimiventes The remainder
of the duodenum exhibits tlie valvnl® to a well marked degree These are
circularly disposed reduplications of the mucous membrane, and, unhke the
gastric mucosal folds, are {lemianciit ami not obhterateil by duodenal disten-
sion Tins disparity in tlie mucous membrane m the first and the remaining
parts accounts in part for the difference in the radiographic appearance
Ijotweon tlie duoilcnal bulb and the remainder of the duodenum
TECHNIQUE
The duodenum must be studied fiiioroscoptcallj and m a senes of radio
grams, tlie former being in part a preliminary to the latter riuoroscopy is
ncco'Nsary not only to study the diiwlcnum m active function Imt aho to
determmo the position in which it miv liost be radiographed
Posture — ^TIic erect position should be used m routine work The majority
of duodenal bulbs arc bc^t demonstratcrl m this position The prone and
supine positions sliould be tried if the erect fails to oilow a satisfnctorv demon
fttration Of the two latter the prone is more likely to present a batisfactonly
filled cap than the supine
Plane — Screen examination is ivImj of importance to determine the exact
plane m which tlic bulb should l>e nidiographcx] Usually an nntero posterior
view IS satisfactory, but at times >n this the ‘•ccond portion of the duoilcmmi
hts directly behind the hulb, wath resulting confusion of the shadows of both
IIG
VLDIEVCARY TRACT
‘'lij.lit rotation of the patient i5er\e^ to the right or left to separate the two
shadows In marked h^persthenla the nght or first oblique view is netes^arj
to show the duodenal bulb unmasked bj the p^lonc antnira Two oblique
Mews ore often nece<isirj to demonstmto the crater of a duodenal ulcer m
two planes
Pressure — ^Ttequenllj it is neccssatj to iiiaintawi pressure on the alnlonieii
dunn^ an exposure for two purposes m the mam
In the hjpotoluc iodi\idual pressure oser the lower gastric pole is required
in order to fill tlie cap satisfictonlj Again pressure o\ er the cap ib necessar)
in order to stud\ its relief niucosol pattern V transparent lambs wool
pad such as is descnlied m the section on the tccliniqtic for the stomach
prp'sscd against the appropriate area of the abdomen bj the screen and
cassette earner forms the simplest means of compression Of the mechnni
cal couiprcssora Berg s is the most satisfactorj for the stud} of tlie duodenal
mucosa
Opaque Medium — IVlintcvec diffcrcnte of opinion there maj bo as to the
most satisfactorj vehicle for the bnnum sulphate in gastnc examinations there
IS no doubt at nil that a plain emidsion containing no food is the most satis
factor} for duodenal insestigalions The presence of food slows the rate of
gastric cMvciiation and makes it a difficult and lengtli} process to obtain a
MOW of the duodenal bulb The bismuth salts arc to he aaoided for tlie
same reason
NORMAL RADIOLOGICAL APPEARANCES
The duodenum can be studied oiiK when filled with a contrast medium
On screen examination when the Ktomacli is filled witli a bannm cream sue
cccding j^n-staltic waxes arc seen to sweep towards the i>xIonis and after a
\anablc number of abortne waves the p}loru9 oj<ens and a small quantitx
of the cream i» shot upwards into the duodenal bulb The fin.t I olus max not
Iw large enough to fill tiic bulb full} bxit usuall} after two or tliree similar
pinstaltic xxaxes enougli is ejectc<l into the duodenum to distend it completeh
The bulb retains its contents for a fexx seconds at mo«t and then b\ a con
tractile xxave passes tie bolus on into the xillous portion of the duodcmim
(i e the portion posses mg pht'C circularea)
The barium cream j asses through the dtimlenuin xi ith considerable rapidit}
and IS normallx considerabl\ subdividcil bv the phc'c nrcul ires of the muco«a
The First Portion of the Duodenum
This is b\ far the most imjKirtant i art of the diioilemim from an \ rax
jymit of X icxx as it is the seat of duodenal ulceration
The firbt jxirtion consists of tl c bulbus duodcni (I ig 79) or duodenal cap
and a variable amount of fcatherx duodenum — le duoilenum sujiplied with
THE IsOR^tAL DUODLNtni
in
\nl\ulT 2 conniventes Ihis i3 a point of importance The normal bulb should
be uniform and regular the normal duodenum beyond the bulb should be
featherj The cap maj therefore be surmounted bj a feathery portion m a
radiogram
riie duodenal bulb prc'^enta n w ide ^ anet j of normal appearances both as to
I
Fio 79 — D aernm of thcnomml pjlonMBnd luodeiuilbull
shape size and position Its shape has been compared uith nianj similes
such ns acorn liazcl nut ace of spades triangle beelii\ e hemisphere etc T1 o
acorn with its ba c dow-nwards is as good a simile as anv This is the form
which tile duodenal bulb most Ijpicallj assumes when it is full Tig 80
after ScJiu- shows the aarious normal tapes
beatures of tins the standanl cap are the rcgiikrlj curved right and left
borders and the concaac base The latter i'» also regular m its curac and is
joined to the lateral margins bj blunt angles or fonuccs The concaa it> of the
base IS due to the bulge of the palonc sphincter muscle and is increased in
hypertrophy of the sphincter The pvlonc canal should join the base of the
cap at its middle (Figs 81-bo)
The cap outline should he regular until n point near its aj)c\ aa here it is sur
mounted ba the feathery shadow cammed ba the vnlaulse conmaentes which
begin at this jximt
118
ALT^IENTARY TRACT
Variations in the radiographic appearance of the normal duodenal hu!b
raaj bo due to
(o) Tlic habitus of the patient
(6) The degree of filling
(c) The posture of the patient.
(fl) HABm,s OF TUF Patient— T he hypersthtnic indnidual possesses a
short squat cap, the long axis of winch may be nearly horizontal and backMard
Fio 80 — T^pes of normal duodonal Imlb I TnanKuIot or prafced hat t>pn 2 Dome
shappil 0 Globular 4 Bu!bou>j ^ Tnincati^l suirar rone R Ilanunrr hra I ehH]'>P of
inromplclo fniins 7 Ale^abuIbiM or jiuto nrnjor 8 Microbulbut or jiiato minor
inclined to some extent In the po>tero anterior view the tap ma\ lie seen end
on, and the lower half thereof maj be hidden bj the pjlonc antrum On
turning the patient into the first oblique i»osition, the pilonis and cap arc seen
unmasked b% the stomach
In the orlliotomc subject, the p>)onc antrum is below tlic pyloric level and
ik'c pj hfuji at T,\\p Iav.i.1*
in tins tj pc IS rather longer than it u. broad, and a <»hort fcathorj plume ma\ Iw
seen at its apex The inclination of the long axis js cither upwards or upwards
and shghtK to the right, and onU slightly backwards
In the hi/jmtontc tv pc the bulb is long and rather narrow It points
directly upwards, or upwards and to the left Quite a lai^e jHirtion of featherv
duodenum maj surmount it
(6) The Deobfe of PnUNO of the cap will, of course, profoundij alter its
X raj appearance This must lie observed very carefully , as it is the commonest*
THE ^Omf\L DUODEXUJI
I
cftu^-c of erroneous din^o^^is o f duo | —
denal m^r 11 e Im;gll]ant^ due to
incomplete filling is tisuallj of a
recognisable UTie Fithcr a small
pool in one or both of the fomiccs or
eKtendmg light across tie ba«e or
if the tone in tiie bulb be uell mam
tamed an outline of the mucosal
pattern is v jsible This last is Ijccom
mg of im.r.,asmg importance and a i
recognition of the normal folds of ^ •
mucosa in a contracted bulb is essen H'
tial in the determination of a barium fc
filled ulcer crater * *
Ific commonest arrangement is f
that of longitudinal folds continuous J* «
uith tho^o of the pjlonc canal [i
(Fig 82) These are not pennaiient ^
but are oblitcrateil b\ full distension £j
of the bulb Occasionally they
nmme a mss cross or honejeomb f' , 1 ,
pattern and in others a radiating
outline from a centralbarium
mass A distinctive feature
of the normal mucosal rug®
in the bulb IS their ficxibdity I
and elasticita They can be
temjwrarily deformed and
obliterated by pressure in
contrast to their comparative
rigidity in duodenitis
(c) Tut PoSTtnt 01 THE
Patii'VT has a eonvidenble ^
influence on the \ raj
appearance of the bulb Its
long axis liecomes more bon J
zontal vvlien the patient |
reclines and frequently its
in'Kj 15 hidden b\ tiie over
lying pylonc antrum This
occurs particularly in
hi postheme mdividuals in .
, . no b — 'Xonnai (Juotl nal bulb compmbvn) to ghow tl
whom the erect po ition is
luucoui pattern
bl Ser al rsti ot.rsnM of (h<> nonnal <luo<leruiI r\tlc
tlic more satisfacton in m liiclt to demonstrate the cap In the erect posture a
ImWile of gas la oceasionaMj trapped m the apet of the \iuU) It js of no
aipiificance except that it must not he mtstaLen for a bubble in a deep ulcer
crater or diverticulum
The Duodenum Distal to the Bulb
Tlie second thm! and fourth portions of the duodenum shon no ndjo
griphic demarcation but arc merte<i into a more or le«s regular loop \3 ft
THE NORIIAL DUODENUM
121
tia 84 — Ncirmal duo»l«'rniin ^nal ehowins the cvelo <f filing
rule there is n suiTicicnt change m direction betA\ecn the first or superior portion
and the romaintlcr to determine the hunts of eftcli, but e%en here the cur\o
uin^ l>e too regular to nlJou of this
On mg nn opaque bolus pass throngh the duodenum, the cap is seen
Fia R — Si nnl nittiof^ram of a itormat duodfiial I ulb
first to fill On tlic bulb contracting a stream of barium is seen to sweep
round tbc diiodoniim into the jejunum in a remarkably fine state of subdivi
6ion A radiopmm taken witli a sufiiciontly ehort exposure will show this
appearance m detail It is unusual to see a solid mass of barium in tlie normal
duodenum beyond the bulb unless with aery free gastric eaacuation This
THF NORMAL DUODFVCnr
123
curious cfTcct is produced bj the \alvMlse conniventes m a ua\ not com
pletclv understood The muco'ial p-ittem in the third jiortiou may be flattened
and longitudmallj disposed u here the superior me enteric vessels cro-is the gut
Tins appearance is exaggerated in arteno mesenteric ileus
Ampulla of Vvteu — In a small percentage of cases this fills uith a
hanum cream and la vi-jible as a small rounded shadow the size of a green pea
dost to the inner border of the second portion of the duodenum Its filling
does not appear to ha\e am chnical significance except that it maj simulate
a duolenal di\crticulum It is unusual to find a rest retained in^tlio
ampulla after the stomach and duodenum are empts doubtless because the
bihata and iiancreatic secretions wash it out
Diodino JFJUNAi Flcxobi — ^T lus forms a fairlj acute angle m the
hjposthcnie indiMdual and often just a gentle bend in the hj'iJersthenic It
shous no sphmcteric action In the hyjiotonic the opaque cream ma> show
slight hesitation before passing tbn flexure but hjqiotonia alone rarely causes
am fccnous duodenal stasis
CHAPTER VI
DLODE^AL ULCER A\I> OTHER IXFLAiDIATORY LE^IO^S
CLINICAL FEATURES
The dvodemm is much the commonest site of peptic ulcer duodenal ulcer
being several times as common as gastric The causation and morbid anatomj
arc similar to those ofgastnt ulcer Thus the> fall into tuo categories — acute
erosions and chronic ulcers
Duodenal ulcer ma\ be met u ith at anj age but in the mam it is a dt ea e of
adult life In children the condition is verj rare and if present is usuallj m
the form of an acute eroaion The greatest age incidence is between 30 and jO
\ear8 Males are more often attacked than females m a ratio according to
6/icrre« of 4 to 1 There is an association hetween duodenal ulcer and
chrome appendicitis the latter standing in a causal relationship to the former
Situation — Over iter cent of duodeiiil ulcers are situate in th e first inch
of the duodenum Acconlmg to CTuirwiowt the commonest site is on the
nnierKirwall next in order of froquenej the posterior wall fcometimes two
are present opposite one another the so called kissing ulcers
Perforation — ^TIus inav be acute or clironic In tlie former the contents
of the duodenum flood the abdomen In the latter the perforation is vvalled
off bj adlicsions of a nearby mscus and a localised periduodenal envatj or
accessor} pod et is formed
RADIOLOGICAL FEATURES
Tlie \ ri} signs of thiodcn il nicer iiia} lie grouped ns follows
(«) The visualised ulcer crater
(11) Adjacent inflanuiiator> spastic and cicatncial changes in tiio hull)
(c) Sicondarv disturbances in the stomach
The Visualised Ulcer Crater
Tins IS the one cardinal and pathognomonic sign of duodenal ulcer Ml
other signs arc susceptible in occasional tnstanccii to other explanations
Z/nre/ay first drew attention to the pcmslent fleck as a sign of duodenal
ulcer Tears were to clap'C before the occasional recognition of a banum
residue in an ulcer crater^m the dufxlenum v^as elaborated b} him and his
pupils in Fngland and bv Akrrlund in Mockholm, into a sjstematicdemonstra
tion of the nicer crater in the majont} of esses but to Ilarclaij is due the
credit of introducing the direct sign m the diagnosis of this condition
DUODENAL ULCER AND OTHER LESIONS
32.
AJtliough in the niajoritj of cises tlie duodenal bulb show 9 a deformity u\
part due to other factorv that due to tlic ulcer itself is of primarj importance
and a careful attempt must be made to demonstrate it in eaery ca'ie (Figjs SG-
89) Ber<j m recent \cars lias stressed the importance of tins and the technique
f m tiC — Puo 1 nal ulo«r on •nlf'nor wall tn fate anil en prej^le \oto f J e mticcwal coronn
broUfl t into v«*ir 1 1 comprr* on
Vjo 81 — BuoOcnal ulcer on tl o I o tenor wail iiccn fii/ie« ai leiiprofle
n'.socinted u-ith his name is the basis of modem examination Jierg nlm^ at
show mg the ulcer crater m tw o jdane^ in profile and face on The essence of his
method IS to use aimed exposures to show the niche m profile and to U'C
graduated compression oxer the bulb to bIiom the ulc-cr enface For the pro
file ML\% pcrccn examination is neeessarj to decide the precise angle m xxhich
the nihogram must l>e taken and rotation of the patient through approxj
match t)D degrees should then bring the ulcer en face Malher Cordincr points
out that as the majontx of ulcers of the bulb are on the nntero lateral and
126
ALIJIEXTARY TRACT
poslcro mcdml surfaces, the profile niche is usuaUj' beat seen in the left antenor
oblique position, and the en face m the right antenor oblique
The CH face ulcer will be imi'^ible in a well filled bulb, and Ba-g uses Jus
‘ graduated coinprc'^sion ” over the bulb to fiatten it, partially emptj it, and
80 bnng the relief pattern of the duodenal iiiucosii into relief
Tins technique finds its particular \alue where spasm oedema a nd scarrin g^
of the Iiulb are all present m slight degree or not at ail In such cases an
antenor or posterior wall ulcer might be entirelj obscured m a well filled cap,
unless carefullj sought for m this manner
An ulcer crater seen face on maj show a difTerent apiicarancc, depending on
the degree of pressure used the depth of the ulcer, and the amount of cedenia
round it Tims a deep crater, witli little compression, may show a cliccrticular
opacitj with a fluid leiel and gas aboce A medium crater with surrounding
(«) t') (<■)
Fio 88 — llitw of ft<luodt,n«n>ulb (o) I'o'lcro ontonor wjlli compr(i»!>ion oin. ulcW
erntof visible* (b) With {mtiont ^t«,htU rotntol iw« «tc now \i<ible (>nipcTiin|io*e*l in tb** fif<t
(c) Irfitcnil (ihowing tikfr > rntpro on Aiiuriornn I |)n^t^rlor nAlls (kmiiiK ^Tho
!<} loni4 H iiuirkotl X
cedema and considerable pressure produces the ‘ rosette ' appearance (/«
cocarde of the French) that of a round central opacitj and a surrounding
transliiccnt zone A fihallow crater with little or no redema, tends to «how a
star shadow , a central fleck with a radiating corona of mucosal plica? Forg-
sell has cmphnsi>,e«l this radnfion of the plica? as n sign of a contracting nicer
This demonstration of the iiUer crater in two planes profile and end on is a
lounscl of iierfection unattainable in some cases Often in the obese hjper*
sthciiK subject w hose duodenum is placed high under the costal arch and is not
8 usceptible to radiosc?opic compression the c« face picture is not fea'-iblc
Again in such subjects tbc bulb niaj l»e hidden behind the pyloric nntnini, and
iml^ one unobscured siew lie iwissible — one which inaj or niaj not Ik? the c-or*
rcct one for the profile \iew of the ulcer In other cases the other factors may
distort the bulb 8 o gro>.«lji that the Berg technique is either iinnecc*s.'ar\ or
inefiectno Imlcoil most ulcers of the duodenum present n bulb deformity
DUODENAL ULCER AND OIHER LESIONS
127
line in pirt to otlicr factors In some the enter is e\ndciit , in others the chs
tortion IS so gross that it is impossible to be certain ^\hnt is ulcer enter either
Jacf or in profile, and nhat is a crevice of norraal mucosa thrown into
prominence bj the surrounding deformity
In such cases it is of first importaiitc to establish one point legarding tlie
deformity, whether or not it is constant Since an essential feature of bulbar
Fio b) — /Ho e Ilisitunll ftoblipicM w» ottl o flu xlcn >1 bulb Inkcn Axitl out comprc'wion
Brio f Til ■uimo % <•« s 1 iWcti with com| n -ahUin uii I eliutt ii s s lUio I iial ulref m ila tw o pi ine*
flcformil> due to ulcer )■> its co nstancy the importance of taking a considerable
s^us ot nidiogmms is otnious
Snue \anation in the appearance must result from the \arjjng degree
of distension as the Imlh fills and empties, but discounting this the defonmt\
must remain substantialU the same in tjTKS and dis]>0''ition if it is to have
nnj sigmiicancc
Adjacent Changes in the Bulb
'Ihe>»o factors aJiicIi produce btiperadtletl deformity in the hiilli — niucov il
adoina, mngeulir spasm, ocatneinl contracture, and 1‘erjfoncal adJiesjon — all
128
ALTME^TARY TRACT
l-ic! 00 — Sfriiil rndii.rniiw of a diicxUnal «t<r proilicini, ptniral bulb <kformih of tbc
or ct»ral branch t>it
tend to cncro Jtli on the (himleiml lumen (IMerai tends to prodiu-e n roimi1e<l
inward biiloe ap-xsin a sharper imlentation and fccarnng nnj assume nnj fonn
Pcnduodtnal adhe«inus maj prwluce contracture or ‘ tenting
l},s the \nr\ing uiter\ention of tlicvc fi\t factors — ulcer crater, cedema,
hpism, starring and adhe-ions — an almost infinite ^a^Iet^ of htilb deformities
niaj lie produced, but thev tend to fall into seteral groujis
111 — Vral rad f>^ram •*!
" fifnrmi I ulli dofoniutv from iuod na) ul«!r
(J) (.FsmvL IUlb DEiORMrT\ — Tlio great mnjontv ofxilccrsfall into tins
group Of the iiinuN motaphofs lucil to dcscnlw tins type the terms coni
I nincli ‘ slniijroch or pine tree deformities are the nio«t comnionlv
upplnahle (figs hO-ht) In thcMi dcfomuties the actual crater tin fre
\ R II— ')
!• 1C j 'vnni ta I ot^rftiiM of «i wt^nOK ng luo Jc ml ul cr
qucntl> be disfififetJisIied an I ImmkIo *t the *ipastic and a*den atou'i element/)
Scamng can onij i>e detennmed after rciieite<l observation during a course of
Biiceessful medical treatment It cannot be separated from the other two or its
DUODENAL ULCER AND OTHER LESIONS
131
pre‘>cncc clefimtcl 3 determined at one imtnl etannmtion, unless tlicrc are
indications of obatructue stasis in the stomach Then scarring sufficient to
produce obstruction can be inferred
(2) NiciiP DEFOR'n'n — ^This tjTC, alreadj described above consists
of a protrusion of the barium filled crater seen in profile It is relatnelj
uncommon alone
(3) Ay IvcrstTRADEFORJiiTi maj be seen in a radiogram nndusualh means
the presence of an ulcer A careful search, after the manner of Berg should
be made in suclt a case to demonstrate the actual crater
(4) The Akfru NT) DiFORMrr\ a comhinTtion of niche and incisura is a
fij J3 — l)u<»«leiuil otrpr two plui*en of fUinp
\cr\ t\pical apjicamnct uith the niche on the lesser curve (left borderland tin
metsura on the right Ixirder U docs not occur frcqiientlj (Fig 95)
{">) DiFORinn or rut Bilu issociartn uttii Distortion or Pirofiic
Canae — Tins occurs tN^ncalU when the ulcer spreads from the duodenum
into the pvlorus The b ise of the cai> is of necess^t^ deformed at least on one
suit h\ such an ulcer The fonc cnnnl is tommonh eccentric rchtn c to the
hull) m such cases
(0) RFTr\cnoN (AKERitM )) — AlerJund his dcscriled a change in the
bulbar contour m the region of the ulcer crater to which the abo\e term has
been applied It consists of a loss of eomcNitj or actinl concantj of the
contour of the capon eitJier side of an ulcer seen in profile Heattnbuted this
to muscular retraction round the eniter, but explanation — that of
mucosal owlcma round it — is the more probihlc
132
ALIMENTARY TRACT
(7) Titc Small Stenosed HirLB — -Marked scamng a^^socmted Mith ulccra
tion inaj produce an irregular microbulbus Associated Mith this there is not
infrequently a dilated pouch formed bj the base of^tlic bulb (usuallv the right
fornix thereof) This type was first debcnbcd by Alerhind and the dilated
pouch has lieen called the ‘ prestenotic diverticulum (Pig 00)
(8) DfFOBWTY FRO’lI PntETRATlXQ UlCFR TIfE \CC£SSOR\ POCKET —
All accessory pocket results when an ulcer perforates the duodenal wall and
forms a localised iienduodenal cavity It is an uncommon occurrence and
may persist as one type of secondary duodenal diverticulum In the erect
position it tyqiicalU displays after a baniim meal has been given the three
layers alreadv described in connection with gastric ulceration — gas fluid and
baniim from above downiwanls It must lie distinguished from a siipn
ampullarv pnmarv duodenal diverticulum the only other condition which can
bimuiate it In the latter the cap outline is normal while with a penetrating
ulcer there are certain chaiaetcnsticb m the radiographic appearances to which
Mnlhcr Cordirtcr Ins drawn attention as follows
Mlicn an ulcer has penetrated into a nevhliouring organ — eg liver or
pancreas — the cap loses its mobility If the pancreas is involved the jvistenor
w all of the duocU num is draw n out into a peak or tent w hen put on the stretch
A diverticular crater may surmount this Occasioinllv tlio normal longituchnal
mucosal folds can he seen bending abniptly into tlie funnel shaped channel to
the crater Ihis dragging on the bulb tcnd» to forcdiorttn it Tlio above
signs may he tabulated thus
(1) Pivation of bulb
(2) \ simped ilcformity with niche
( I) Accessory pocket or divorticuliim
(4) Divergence of rug's into the funnel shaped cliannel
(O) Foreshortening of bulb
Secondary Disturbances in the Stomach
1 he most frequently observed of these is hyptrpeneiahis It is held by
ponic f iiat tins is tv idence merely of a predisposing habitus but m many ca«cs
It IS too marked in degree to be accoiiiiterl for on tiiat ground and must be
tvplaiiicd ns a reflex from tlie duodenal focus of irritation This hypcrjitn
stnliis occumiig with a patent pvlonis results m rapid gastric evacuation
Ivrrta’ic tn (h>> Onckveis of Ihf (jasirte rtigtv cs|KJCiall\ along the greater
cnrvt IS a common otcurrencc This is shown m the filled gastric lumen l»y
crcnation of the greater curve and by widening of the rugas in the relief pattern
It H commonlv ascribed to an associated gastntis but may also be a rcflcv
plicnomenoii on the part of the gastne mutosn and miisculans mucosa?
Hy]i€rtonu/i is frequently BCcn but unlike hy pcrjicristnUis can be at'couiitcd
for ns merely an indication of tie habitus of the patient Duodenal ulcera
— (rt) TIio jirt^Uuotic <ii%onii:tilum of \kcrl«n<l
(|iif>il<‘nat bulb
(ft) Ul«*r crar<*r on Jfio ba**? ol the
tjon tlmxigli commoner m pervons of hjperstliemc l)uild la bj no means con
fined fo them, nnd h^ iwtonin and slow evacuation are not tmeommonU present
Jndect], the oh-enations of Ilttrsl Tcj’anlmg the pjJonc {unction tn gistnc
132
ALBIENTARY TRACT
(7) The Small Stenosj^d Bulb — ^Marked scarnng ns-sociated with iiiccra
tion maj produce an irregular microbulbos Assoaatedwith this there is not
infrequently a dilated pouch formeil by the base of^tlie bulb (usually thenglit
fornii thereof) This type was first described by Alerlund, and the dilated
pouch has been called tlie “prestenotic dirertieulum ” (Fig 90)
(8) Defor'utv from Pexetratiso Ulcer, tme Accessory Pockct —
An “ accessory pocket ” results when an ulcer perforates the duodenal wall and
foims a localised periduodenal cavity It is na uncommon occurrence, and
may jiersist as one type of secondary duodenal dnerticulum In the erect
IHisition It typically displays, after a baniim meal has been given, the three
layers already desenhed in connection with gastric ulceration— gas, fluid, and
binum from «iho\e downwards It must be distinguished from a supra
nmpullary primary duodenal diverticulum, the only other condition whicli can
simulate it In tlie latter the cap outline is normal, while witii a iienetmting
ulcer there are certain charactenstica* m the nuliognphic apjieirances to which
Mother Cordiner has drawn attention as folJons
IMien an ulcer has penetrated into a neighbouring organ — eg liver, or
pancre is — the cap loses its mobility If the pancreas is mv ol\ cd, the posterior
wall of the duodenum IS drawm out into a peak or ten( wlicn put on the stretch
A divertuiilnr crater may sunnount this Occasionally tlie normal longitudinal
mucosal folds can be seen bending abniptly into tbe funnel shaped channel to
the crater Tins dragging on the bulb tends to forc-.horten it TJie above
signs may be tabulated thus
(1) Fixation of bulb
(2) V glia{)ed deformity' with lucbc
(3) Acce‘'‘'ory pocket or iliverticulum
(4) DuergeiKe of nigx into the funnel simjied channel.
(5) Foreshortening of bulb
Secondary Disturbances in the Stomach
Hie most frequently observed of these is hyperperistuhiB It is luld by
‘tome that this is evidence merely of a predisposing habitus hut in many ca«c3
it is too marked in degree to Iw accounted for on that ground, and must be
explained ns n reflex from the duodenal focUi> of umtntion This hyperpen
stabis oceurrmg with n patent pylorus results in rapid gastric eyacimtioii
Increase in the thickness of the ijastnc ruga especially along the greater
curve, i& a common occurrence Tins is shown in the filled gastric lumen by
crenation of the greater curve and by wadetung of the nigie in the relief pattern
It is commonly nscnlicd to an associated gastritis, but may also l>e a reflet
plicnomenon on the part of the gastric mucosa and imisculnns mucosx>
Uypertonus is frequently seen, but unlike hvpcrpenstnlsis can be accounted
for as merely an indication of the liabitus of the patient Uiiodcnid ulcera
(-J) {«*)
^ lo PO — ( i) T1 <? pnMtCMot c <l > crt cu)um of VVctJuh 1 (fe) T, I cr cratrr on tl o bft«i of tho
IiKMlmsi bulb
tion though commoner in jiciMinn of Inperathcmc build is h^ no means ton
fined to them and h^ potonia and slow e\acuation arc not uncommonU present
Indeed the ob'«r\nlions of //«rst regarding the pjlonc function in gastric
134
ALUrENTARY TRAOT
ulcer and its effect on tho function of the stomach applj ■with equal force here
In duodenal ulcer there maj be found one of the three abnormalities of the
p^lonis — achalasia pylorosjmsm, or ot^nic stenosis, or a normal pyloric
function may obtain
The^e gastric changes constitute, therefore, mtcresting but unimportant
coniirmator} parts of the radiological picture of duodenal ulceration, and of
themselves afford no specific diagnostic indication of ulcer m that site
In a certain percentage of cases localised tenderness on pressure over the
duodenal lesion is present It is said to be the result of peritoneal mvolvcDieiit
and periduodenal adhesions It is a variable sign Frequently the tender
jwmt is m the cpigastnum well above the duodenal bulb It is of no value as
an independent sign
The lost word in tho discussion of the X raj diagnosis of duodenal ulcer
should be to emphasise the cardinal importance of the niche, the ulcer crater
itself loo often it is not possible to demonstrate it, and reliance must he
placed on the general bulb dcformitj — tho coral, the pine tree, tho clover, etc
IMiile these are most corumonlj due to duodenal ulceration thej maj result,
in occasional cases, from such diverse lesions as healed ulcer duodemtes
cholecystitis, apjiendicitis penduodemtts, or even mere incomplete filling
The niche itself properly demonstrated end on and in profile is the only
pnthognomomc sign of activ e ulceration, and the otlier deformities of the bulh
are more projicrly indices ofafl*ociatcd<edemalous, spastic, or cicatncialchanges
Healing of a Duodenal Ulcer —This is a problem which frequently presents
Itself 111 radiological practice, and is often a difficult one Whilst it ma\ be
fairly simple to establish the presence of a duodenal ulcer initially, it is often
a matter of great difficulty to decide how much residual deformity will ulti
match occur on healing
In considering this the factors producing the deformity must be borne m
mind, and it is of first importance that the initial radiograms of the ulcer and
the succeeding check exammatloiis be of the highest quality Only then can
the graclanl dmppenrance of the deformity be analysed
To determme tho presence of a healing process the ulcer crater should I>e
looked for first It must disappear Its radiographic diwvppearancc is not
conclusiv e, as tho crater may lie \ isiblo only because of the surrounding mucosal
cedema The cedemo is usually the fimt of the factors to disappear In the
case where the crater is invTslble on the disappearance of the cedema the
persistence of a spastic incisura of the bulb may indicate that tho lesion has
not entirely healed IJie spasm js, as a rule, the last temporary factor to
disappear, leaving a varying cicatricial residue This last may range from a
virtually normal hull) outline to quite marked atenotic deformity In the
latter case, the fact of healing cannot be established by radiographic means
alone In the jirtsenco of marked cicatnsatinn prolonged alisenee of all symp
toms would be neces-sary to warrant such a conclusion
DUODENAL ULCER AND OTHER LESIONS
133
It follows from the abo\c considerations that a healed duodenal ulcer can
w ith certaint j be show n radiographically to be go only if no cicatricial deformity
remains after Iiealing Tlie more the residual scarring, the less certainty is
there in the radiographic demonstration of hcahng, and the more reliance must
there be placed on the chnical evidence on this point
In an extreme case, where a secondary diiertjculuni has followed ulcera-
tion, It rnaj be quite impossible to distinguish this from a deep ulcer crater hut
the deepest of craters usually shows some lessening of size under vigorous
medical treatment, and if no diminution in size is observable in a senes of
examinations sinread o^er a course of treatment, the" presence of a secondarj
diverticulum or pouching is to be suspected rather than that of a deep ulcer
Gastric Stasis following Duodeoat Ulcer, — ^This is a not uncommon
sequela of chrome duodenal ulceration, and is caused chiefly by cicatncial
contraction, with a supendded element of mdema, if active ulceration persists,
ns it usuall) does
In the less severe degrees it maj be easj to demonstrate the stenosed
irregular passage, but m tho severe degree this ma\ take considerable pains and
patience The bccondary gastric signs, as described under pj lone stenosis will
lie present to an extent depending on tho seventj of the narrowing
It mav not lie possible to determme vrhether the obstruction is in the bulb
alone or m the pylorus as well, but the point is of little importance, so long as
there IS no sign of involvement proximal to the pvlonc nng This would raise
the possibility of caremoma a condition which moj virtuAll} be loft out of
consideration on the distal side of the sphincter
DUODENITIS
Till** lias become a populir diagnosw of recent j ears and although doubt has
frcquentlv been c,'ist on its existence, it has now been proved patliologicallj
to be a clinical entitv A certain degree of duodenitis nearly ahvavs accom
panics a duodenal ulcer, but Airi/m has published a senes of thirty two cases
in which the presence of duodenitis and the absence of an active or healed
nicer Aaie l/ee/t proied
The bulb is the most common site but the inflammatorj process may ex
tend dowm as far as the nmpuUa of Voter (i c tho point of acid neutralisation)
JfcCarfj/ gives an account of the pathological features as those of cellular
dtstruction with cedema, vascular congestion, and leucocjtic infiltration
Macroseopicallv , tho mucosa is cedomatous and reddened, vnth occasional
minute erosions
Tnt X-KAV pFATcnES are dejicndcnt on spasm of the musculans and cedema
of the. mucxjsn The changes may bo seen in the bulbar and post-bulbar portions,
and in tlie filleil and emptv lumen In a marked case thej are fairly typical
/« /hi bu}h, the first point to lx? noticed is its fillin" Owinc to general
13C
ALUEElvT VRY TRACT
increased tonus in the bulb the contrast medium •\\hen projected through the
li^lonis fails to distend the cap to its normal proportions and ulnte^cr
incomplete filling does occur is sjieedilj dispersed A radiogram taken at tl e
moment of filling show s a small cap with a ha 2 > or spikj contour If taken a
second or so later the mucosal pattern of the bulb becomes \T«ible (if not of
itself then uith graduated compression) It takes the form of a coarse retieu
lum the result of broadening and eoarsetung of the mucosal folds Together
uith tins broadening is a loss of flexibility so that it is difficult to obliterate
tbcm In pre‘!sure Between the folds there maa occur irregular deposits of
barium simulating an ulcer crater but no true ulcer crater is seen Tins
though a negative statement requires emphasis since the presence of such a
crater must lie mcticnlousU excluded before pronouncing the condition to lie
the simpler one Distinguishing features are the absence of a niche projection
m profile and the mconstnnev of the pseudo niche at subsequent examination
rhe duodenum ! fiuee.n Me hutband IhcamjmUa if iiuohcd m the mflamnia
tion, shows radiographic changes depending on the decree of mucosal cedema
and muscular bxTicrtonus
During the plia«e of filling the barium filled lumen is seen to l>e narrower
and Its margins scallojied to some extent Tlie latter is due to the indentation
of the banum shadow b\ the cedematous mucosal plica? \\ h^n (lonstalsis has
emptied the lumen a coarse mucosal pattern ts visible similar to that seen in
the bulb
According to hirUiii duodenal obstruction rarely results from simple
duodenitis nor is gastric stasis a feature thereof
PERIDUODENITIS
This too Is a popular diagnosis of recent \cars and there is a tendency bo
to label any vague irregulanty in the iluodenal contours in viliicii no verv
(lefimte pathological lesion is dernonstrahle It is a comfortably \ague and non
committal diagnosis one which does not tempt to surgical interference ami
f ne to W avoided unless on the clearest possible evidence
Dura/ desonljes two tyi>es jienduodenitis mvolv ing the bulb and pen
duodenitis involving the third and fourth jiortions
Bii^bar Peridcodfmtis mav involve the whole bulb or merelv the ajiev
In the former the bulb is Bmall adherent irregular in contour andinettensiblc
Its diflirentiation from tnie diiodeiutLS would thus depend on the demonstra
tion of a normal mucosal pattern in the bulb a thing rather difficult to do
because of the wirous thickenuig In the type limited to the ajwx of the bulb
the main body oftliebulbisnornialin contour and only its apex Bhowsirregular
constant contracture \nnou« causes arc asenbed to this condition In
some no cause is demonstrable others result from cholecystitis duodenal
ulcer, or adhesions It is obvious that in those cases in which thepnmary cause
in the gall bladder or duodenal mucosa is visible the penduodcnitis is an inci
DUODEWL ULCFR AND OTHER LESIONS
137
tlentil atatc quite oa ersliadoircd hy the major lesions, and the closest search
must be made for such pnmar> condition m all cases in ^\hich a suspicion of
bulbar periduodenitis is raised b^ the radiological examination The demon
stration of duodenal ulcer and gall bladder disease is as a rule easj , and an\
considerable adhesions maj caxise a displacement of the bulb either in front of
or behmd the stomach The anteposed bulb ma> result from its adhesion to a
large dilated gall bladder to the antenor edge of the liver, or to the anterior
abdominal uall The retroposed bulb « usually adherent to a small retracted
gall bladder, or to Spiegel s lobe of the h\er
Pu’inuoDEXins or the Third and Fourth Portions results m a
mild stenosis and a mild duodenal ileus Its appearances are discussed in
that section
pEniDLODEMTi*; AFTFR CifOLECVSTECTOiti — The duodcHa! bulb \erj
coiumonlj ehous a deformitv following this operation, the result of adhesions
These if marked maj cause duodenal stenosis and consequent post •operative
abdominal sjmptoms Thea may, however, e\i«»t m the presence of complete
clinical cure
DUODENAL FISTUL/E
These maj be external or internal
External riSTtur are rarely seen m X raj departments Thej mij
result from operations on the duodenum, bile tract, or right- kidney, or be due
to pathological conditions of the duodenum (notably ulcer) or to injury Tli©
condition is usually ciidcnt clinically from the nature of the discharge and its
digestive effect on the «kia, but in tho«e cases where there is slight discharge
onlv and little cutaneous reaction the nature of the fistula can easilj be do
termmed hj injection of an opaque medium, e g barium cream sodium iodide
or lipiodol ami its radiographic demonstration in the duodenal lumen
Oi the Internal Fistulx the chotenjilty-duodenal lypt is bj far the
commonest These result usuallj from ulceration of a gall stone through
into the duodenum or from perforation of the gall bladder bv a
duodenal ulcer Iistulx due to enremoraa have been recorded The radio
graphic dcmonitrotion of these llstulte depend* on observing the passage of a
ivinam t}/eg,‘9}) IdwJ/icr Jf the jiiw Si), thi?
toridition IS evident, but if not, a lateral rndiogram is necessary to diiTercntiate
the banum filled gall bladder from a duodenal diverticulum
llie next commonest tv*pe acconlmg to and Jfof/t are the
{foc/io-duodenal J(Sfu/cr ansmg from ulceration of a gall-stone impacted in the
common bile duct W ith good fortune barium maj pass into the bile ducts and
render the fistula evident radiographically, but tins does not alwaj’s occur
Rarer fistula* arc those between tbe duodienum and the sfomach colon and
right rtnal pelm rcsjiectivelv Tlie rfMorfeno-^a^fne type is best demon
stinted b\ a hammi meal , the others by a banum enema and instrumental
pyelograin respectively
CHAPTER XII
>n«iCELLAXEOUS DUODENAL LESIONS
DUODENAL DIVERTICULOSIS
Tiie diagnosis of this is e^elusivelj radiolt^ca! as the majonty of cases are
symptomlc'ss and m the rest the symptoms are m no way characteristic
Case in 1913 iias the fiiNt to diagnose a case by a banum meal
Frequence — Ltnsmayer, in 1,367 autopsies, found duodenal dnerticula
in 3 3 pet cent of caees
The percentage found in baniim meal exammations \anes, accordmg to
different investigators between 18 per
cent and 6 19 per cent Case (1920)
in 6 S47 banum meal ctnmmatioos,
found diverticula in 1 2 per cent and
Spntjgs 3 8 per cent m 1 000 cases
Ci-tssmcATiON — Odgers group-
tngappears to be the most ^tisfactoiy
He (brides duodena] diverticula as
follows pnjuary secondary and
ampuVary (Fig 07)
Pnmary Diverticula
The diverticula of this group show
the follovring characteristics
(1) They occur only m the second
third, and fourth parts of the duo
denum Hie second portion is much the commonest site, about 75 per cent
of all pnmary duodenal diverticula being in tins segment A large majonty
are situated within an inch of the ampulla of Voter — the “ thverticules
penvatenens of Lelulle A second fairly common site is at the duodeno
jejunal flexure Here they project upwards
(2) They are sometimes multiple, two l«ing present, and, rarely three
Mhen two are present, they are commonly situated one on either side of
the ampulla
(3) Tlicy arc more commonly on the concave surface of the duodenum and
grow into, lichmd, or against the head of the pancreas Sometimes they ho
Iiehmd the duodenum, and if large they may sag downwards and he below
the duodenum
>!(, 97 —Tvpefi of duodenal divcrticuts
I Scoondary 2 Pnman 3 AropuUaty
13S
SriSCELLANEOUS DUODENAL LESIONS
139
(4) They are flask shaped mucosal protrusions of the mucosa through the
muscular coat, sometimes carrjung Antli them an expansion of the musculans
(5) They are best de^ eloped m elderli patients
(6) In size the\ \ar> from a pea to a walnut
(7) TJiey are probably of congenital ongm
Kellogg dindes the above class into true and fal-e dnerticula according to
the composition of the nail thereof The true diverticula have a wall including
all coats of the duodenum These he
regards as congenital False diverti
cula, he states, are acquired and are
composed mainly of muco-sa
PathoivOOX — ^The great majority
of these diverticula are disco\etcd
accidentally and cause no pathological
changes In a small number of cases
changes do occur and are associated
with symptoms Odger gaes a full
account of the sequela? which may
occur the best established of which
are
(1) Ditcriicuh/it -“This may go
on to nleention and perfontion
(2) Pcridiierlicuhlis with
adhesions to the pancreas
(3) Mechaiwcal compression by a
distended dnerticulum on the duo
denum and common bile duct, causing
duodenal ileus and biliary obstruction
respectiieh
Dumleiutis cholangitis acute
and chronic pancreatitis are rarer
complications which ha>e l>cen dc
scnbeil In one case a cliolesteriii stone waa found in a di%ertieuluni
The Sv^irroMATOi oo\ m those coses which gi%e n^e to symptoms falls
into one of se^eral groups
(1) T'o^iie rfi^ftstirc dtsiurbance with distension, flatulence, and nausca
(2) Pepfic u/err sgmpiom complex
(3) Pilifirjf symptoms, with jaundice and colic These occur particularly m
penvntenan jiouches
(4) Symploms of acute panercahtts
\ R.\\ Featebes — ^T he ohanvctertetic feature is the presence of one or
more rounded banum shadows near the concave border of the duodenum
(Figs 9S 100 ) Under screen examination the pouch can be made to fill from
lie 08 — Small iiuoiierial cb\(Tticu1tim near
the ftmpulta
140
ALDIEXrAR'i TR\CT
and emplj into the duodenum and tendeniess over the shadou indicative of
diverticulitis nuij be determined rivation of the diverticulum luav lie
noted on palpation This is of no great significance since vv hile it may l>e cine
to pondiverticulitis it maa be due merely to the i>ouch being deeplv
embedded m the pancreas The presence of stasis in the poucli is of import
nnce (Fig 101) The vnater has seen two cases in vihich a peptic ulcer
gj mptom-complev was present and in which six hour stasis occurred In one
ha aj Large hcrl ill im |t } of (li> |>or(ion f f t> t- iuodenum Stas 4 m-ciirml in it
uj) to " ho ir« Tl r (uvatar rune of the bCottiu 1 iJond an a.-woc «teil gailnti«
of these case>i removal of the diverticulum was followed bv <lii.api>eamnce of
tilt svmptoms
The mucosal relief pattern mav in wune cases be traced from the duodenum
tbroiigb into the poiicb
X-sunllv the erect posture !-» hufliacnt to show these diverticula and in this
jwsition a horirontal Hind level mav be visible if the pouch be large enough to
contain gas ‘xmictimes the horizontal posture is nccessarv to fill them This
applies particularly to those projectmg upwards from the duodenojejunal
fievure Pressure on the ducHleno jejunal Hevure may by distending the
duodenum help to fill them
RrrrFEESTiAL DrACNosis— In most cases the nature of the condition is
cjuilt evident but at times it ma^ be mistaken for other conditions The
'\nSCELLA>EOUS DUODENAL LESIONS
141
comraonc'it error is to mi'jt'ike a direrticiilura of tlie fourth part of the
duodenum for a niciie on tlie lesser curve of the stomach This simulation
occurs onl> when the lesser cur\B of the banum filled stomach half oaerlaps
tlie diverticulmn and its true nature is apparent as peristalsLs proceeds
Diverticula are distmguislicd from other shadows which maj be present in
the neighl ourhood of the duodenum — e g calcified gall stones or glands — bj
the x>tnnanence and lessor densitj of the latter
Primary diverticuh near the ampulla nuiv l>e indistinguishable from the
ampullarj ty^ic and if near the first part of the duodenum it mav be difficult
to djstingimh them from sceondarv
ilnerticula Defornntv of the bulb
usualK present m the latter afford**
the clue
Secondary Diverticula
rhevt, arc found onlj in the first
jiortion of the duodenum have a
(Oinplete muacuhr coat and arc
‘‘Ciondnri to an adjacent Ic-^ioii
mo t commonU a <luodenal ulcer
rhej mav be either puhion or trao
tioii and arc rare oompaieil with the
pnnmrj vnrietv
Of the puUtou tjpc the most
lommon is that found opposite
ulcer scni> flie so irrmg causes con
tracturos and the shallow ptnich so
formed gradualU becomes dccjier by
(ontinued pressure The neck of the
{>ouch IS usimll} wade
llihlic has dcscnbotl three cases of ulcer diverticulum m which
a dense fibrous sac was formed the liovrel wall having been destroved
ht tileeratiijn
The fraction group of *>ocondarv diverticula result usualh from the drag
of ndhcsion-k between the diiovlenum and gallbladder Ios.er curve or
apj>ondi\
\ HAV !• 1 \Ti iiES — Tl ese divcrtiiiila tend to be larger than the prinian
tvjxr and are often irregular 111 shniw and wide necked The> are a*ssociate<l
with some defornntv of the diKHlenum from either scarring or ulceration
^metimes thc«c diverticula are lai^e and would be more accuratelv de^cnbeil
as pouebmgs of the duodenal wall with no appreciable neck These larger
more ojicn pouclics merge with IJie group of cases descnl»od under the term
looped duodenum
142
ALB1ENTAR\ TRACT
liiE S\ MPTOMATOLOOi of secondaij dnerticula la that of the priniarj
leaion but occasionalK thej are associated uitli dyspeptic svmptoms e%eii
iihen the primari ciusatiNo idcention lias di‘«appeared
Ampullary Diverticula
lv\o tj|)cs of these occur
{!) W hen the pspilh of the bile and pancreatic ducts opens into the fiindiw
of n small duodenal pouch 1 his has no clinical sigiuficancc Its onlv radio
(»)
Fl 101 IJiN riic il im of Iho iwon 1 porttnn of il o I odfm in (n) (More ftftpr n I nnum
moil <0 On 17(111 nc (t o ato nncl
logical Significance is tliat it cannot be distinguished fixmi a pen
vatenan diverticulum
(2) Dilatation of the nmpulln of \ntcr itself TJie cause be it congenital
oracf/mred isunfcrtam PosaibJy scone develop as a result of impaction of a
gallstone It is ui importance chmrallv according to Cu?e v\ ho states that it is
associated in ‘’0 per cent of cases with chronic pancreatitis
Uadiolooicai l\ these apjiear as small round or ov al barium filled pouches
a few inilhmetres m diameter in the isceond portion of the duodenum at the fiit<
of the nmpulln
Tlie ampulla of ^ atcr inaj however fill with an opacjue medium apart
from either of the above two abnormabtics This is a not infrequent occur
rcncc and without significance except in the matter of differential diagnosis
5IISCELLANE0US DUODENAL LESIONS UZ
It IS seen radiologjcalJ} as a small ileck medial to the mid point of the second
irtion of the <lttodenimi , mobile, painless on pressure, and showing no fluid
pels such as arc seen in true diverticula
CHRONIC DUODENAL ILEUS
n ifltc was the first to draA\ attention in this country to tins condition
I a clinical entity Simultaneously it had been recognised by American and
rciich observers As described by WtlLte, its essential feature i* a pirtia!
jstniction of the third part of tho duodenum by pressure on it of the superior
escntcric vessels and the mesenteric root m which they are contained
raas and liecL have drawn up a wider classification, on which the following
based
(1) Non-obstructive Ileus Megaduodenum
(2) Obstructive Ileus
Intrinsic Trom neoplasm duodenitis, congenital atresia, diverticula
Extrinsic Chronic arteno mesenteric obstruction, adhesions, jejunal
cnosiN after gastro jcjunoslomy, pressure from extrinsic tumours of glands
incrcatic abnormalities such as tumour abscess or annular iwncrcitio head
irrounding the duoilomun
legaduodenum
This type is easily rccogiused radiogiaplucally, ns it is not dej)6ntlent on
rgnmc obstruction 1 w o theories arc held regarding its retiology that it is a
angenital abnormality, and alternatively that it is tho result of a neuromus
iilnr incoordination and allied to Hirschsprung s disease Proof of either theory
i, so far, wanting Patients oxhibituig this condition arc of liyTiosthcnic type,
nd the diiodenil cap is inv olv ed in the dilatation In the erect position Iwiruim
;nds to collect m a ixfol in tho dependent portion of tho duodenum and
uodeimJ bulb Examination m the supine or prone position serves to outline
(le duodenum more fully , and also shows free passage of the contrast medium
ito the jejunum The inucosvl pattern of the duodenum is unaltered in
us condition
ibstructive Ileus from Intrinsic Lesions
Tho'se lesions are rare Home of them cNtrcmely so In addition to tlie
bstnictivo dilatation of the duodenum, there may be present in the case of
omo of them tho ladiogmjihio evidcneo of the causative lesion
Ibstructhe Ileus due to Extrinsic Pressure
CInef amongst these arc arteno mcscntcnc occlusion and jejunat obstnic-
lon after gastro jejunostomy
In the first of tho«e, f/iromc arteno mesenfenc orchtsiOK, the essential factor
144 ALniEXTARY TRACT
in the "etiologj is pressure of the stipcrior mesenteric vessels and the
mesenteric root
\n\ factor vhich lessens the angle between the supenor mesenteric arferj
and the aorta will tend towards duodenal occlusion A congenital abnonnalit\
might do so and this is doubtless the evplanation of tliase cases occumng m
childJiood with gastroinegaly and megaduo<Ienum up to the point of crossing
of the vessels
As the condition usuallv deaelops m adult life another factor must take
effect some traction on the mesentery and one which will account for tlie
intennittent nature of the sjmptoins Knteroptosis provides tins effect in
n a Koral r«<t >f:rum of a cain? of arUr n n esonten cluoJcnnl it? a
(prp\^l at o| (ration)
two wajs — 1») the drag of the small intestine on the niesenterv and b} similar
traction of the right colon on the iiicscntei^ when the colon is unduly mobile
and dejicndcnt and the ca turn pto*>od into the pelt is In rare cases an ahni r
ninl right colic arterj is the offending a cssel desccndingnlmost terticallt acro-vs
the tlnodeniifii as desenhed bt Oregotre
T! c symplomnlology is suggeslite a bistort of bilious attacks in a tiscerop
totic ttjK* of female pitieiit gradually getting worse after tlio age of 30
epigastric discomfort and flatulence following all meals and reheted b^ It mg
down oresiiccinllj tbegemipectoraI|»osition The bilious attacks ttpicallt
consist ofa dat ofhcadacliL naiiNoa and epigastnc discomfort follow edbj tc niit
ing at first clear and later bibous Tollowang tins the fitmptoms art rehctctl
Constipation usuallt ushers in the attacks which tend to recur etcr^ month or so
MISCELLANEOUS DUODENAL LESIONS
145
Rathograjilnc Features — All degrees between an apparently normal duo
denum and gross dilatation may be found Tlie gross degrees are rare but minor
degrees arc not uncommon and ma\ require no treatment In mild cases
there ma^ he no abnorrnalit} to be seen m the duodenum lietncon the attacks
In an establwbed case a topical picture is pre-^nted (Figs 102 103) The
duodenum IS dilated mav be grossly so The vnlvula. conniacntcs persist but
ire thin and w idoU spaced m gross eascj, fliis is due to the stretching of the
mucosa between the \alvtilaj and is not seen m congenital megaduodenum
Fio 10" — arteno meinMilfnc ouodoi»»i item sup n
Screen c’cnmination presents a tjpicoJ appearance The duodenal peristalsis
IS actiae and often writhing and rc>er«c jicnatalsia commonly present gives
a to and fro or jiendulum moaeincnt to tho duodenal contents which is quite
chatactcri'.tic of obstruction Often the appearance is cunouslj like that of a
reaorsmg cog wheel
On tracing the duodenum up to the point of obstniction it will be seen
tliat there is no sign of annul ir constriction but that the bowel is flattened
against the spine its lumen being redured to a % ertical slit A further charac
tcnstic feature is tho appeamnee of the muco&al pattern frcquentlj in
14G
ALRIENTARY TRACT
these cases the normal cross hatching of the phcse changes at the point of
obstruction to longitudinally disposed mgie Owing to the intermittent
nature of tiie dilatation in manj of the cases it is of importance to examine the
patient radiographically at the beginning of the attack If seen at that stage
the radiographic picture is definite and characteristic
Obstrlctio\ i ROM pERiDUODEsms — This ppocluccs ii niild degree of ileus
since the obstruction is not gross It incseiits certain radiological features
uluch ninj help to distinguish it from the arteno mesenteric aarietj Tlio
ob'.tniction is more constant Two manaeuvues are aaailable to test the con
stancj or meonstanej of an ileus Hayes method consists m attempting to
raise the mesentery bj manual palpation with the patient m the erect position
and 80 relieving the obstructive pressure on the duodenum It is a difficult and
uncertain procedure and its aim is much more surely accomplished bj placing
the patient in the Unco elbow position If it is too difficult to screen the patient
m this position a compromise may be adopted — that of the \cntral jwsition—
with cushions so arranged under tlie pelvis as to prevent direct jiressuro on
the abdomen
Tlic‘«o procedures il successful relieve the obstruction m arteno mesenteric
ileus but not in that due to tienduodenitis Posture of this tvpe is al o a u«c
ful therapeutic measure in arteno mesenteric ileus and the relief from sj mptoiiw
so obtained forms a theniiicuttc diflcrcntial test
OnsTfiKTros irom Adiifsions and Bvsns congenital and acquired form
a not uncommon group The radiographic appearance mav be ver> varied
depending on the ilisposition of the bands biitthcj are less hi elv tobeiehevefl
bv posture than the true arteno mesenteric variety
Obstructiox from PBEssrnE of FxrnrNsic TuvrotRS — Carcinoma of the
head of the pancreas maj obstnict the distal portion of the duodenum so ns to
prodiic-c ileus but more coiiiuionlj the whole duodenal loop is stretched and
ilatteiicd loiind the enlarged |»aiicrfitic head In a ladiogram after a barium
meal the stomach shows dilatation and stasis and the duodenum takes the
form of a thin streak m rather a wide circle A cj st or abscess of the pancreatic
head produces n similar appearance
Kellogg has collected from the literature twenty five cases of duodenal
obstruction from annular pancreas the head of the pancreas being in tlie form
of a ang sdemanchag (he daodenatn In the ninjorU; of these the [iroxuna)
duodenum was dilated
Ilels lOLLOwiNQ GASTROJEJUNOSTOMY — This m the wnters cxpenence
is the commonest tvjic of chrome duodenal ileus It raaj occur m several of
the stenotic scqticlT of that operation but it is most marked when tlie stoma
and adjacent jejunum are stenosed and tbe pjlorus patent If marked tlic
ileus inaj be gross In contradistinction to the arteno mcscntenctjifxjofileus
tlie dilatation involves the whole of the duodenum and the proximal limb of the
jejunal anastomotic loop
MISCELLANEOUS DUODENAL LESIONS
147
Duodenal Ileus m Children
Tho condition is rare in children nnd falls into two classes
(1) The acute tjpc from gros« obstruction — either arteno mesenteric or
atresic ihesc arc not usually seen m an X ray department Schinz and R 11
Rolling liave each reported a case of congenital atresia m uhieh the proximal
duodenum reached a large size and formed n bulbous sac ns large ns the stomach
In the latter s ease this uas seen radiograplucallj eight days after birth
(2) The chrome tJ^)e getting uorse ns ptosis dorclops GastromegaK
develops more mnrkedJt than m adults and may in the radtographicevamina
tion mask the duodenal ileus Miller
and Courlnei/ Gage liavc reported a
senes of this tyjic
Duval reports a case of cyclical
vomiting of infancy in which a
tjpical arteno mesenteno ileus was
found with violent to and fro pen
stahn The attacks were at once
relieved bj the ventral posture
MEGAOULBUS
Iho duodenal hull) maj bo largo
from several causes
The congenital type is rare It
IS recognised hj the considerable
dispantj between its size and that of
thenntrum nndb) theentireabscncc
of obstructne abnormality distal to
It (lig 104)
A milder degree of dilatation is
often present in hyposthemc in
dividuals and IS reasonably account
able as Iximg due to diminished tone
A thmf typo is that due to some
obstmction in the duodenum distal to it such as senmng from ulcer at the apex
of tho bulb or stenosis of the dumlenuin at the junction of the first and «ccond
portions by cbolccystic adhesions or periduodenitis The radiological difier
entiation of these types depends on the recognition of the obstructive lesion
or the hviiotonia or their nb once m the case of the congenital vnrietv
MICROBULBLS
Tho duodenal bulb may bo nnatomiealh small in which ca«e it is regular
m tontonr or from cicntncial contracture when it is irregular or finally from
general spasticity when it fs unifonnly spiky
148
ALIMEM^RY TRACT
DUODENUM INVERSUM
Tins term lias been used to desenbe i reversed disposition of the duodenal
loop the food tra\ellirig through the duodenum in a clocks ise circle instead of
the normal Two varieties are <Jesenbed a mobile and a fixed
Mobile Inversion — This nbnomiahtv is dependent on the presence of a
meso duodenum which allows the first and second portions to sag down and
Fio lOj Moblot>f>pof I Oil n( in It \ eis ini i>r loopoil 1 loden in
80 rexetbc the direction of the dtiodcnil looi» associated with
a hjpotonia
Allied to tins is the condition dcsenbed as loojifd ditodenvtn in which tlie
first i>ortion of the duodenum is dilated and possesses a mesenterx (hig
Thus mesenter\ is siiort or non-existent at the pxlorus and bulb a result
when a banum cream passes through the pxlorus with the patient erect it spilL'^
down into the dependent loop and then liec-ause of the lUhtatiim tends to
fomt a pool This empties into the second portion hj oxerflow flie drag of
tins loop often causes a fiattening and distortion of the hulb
misci:llaneou& duodenal lesions
149
In the 'supine and prone positions the looping is less e% ident, or the loop may
be cntirelj restored to the normal position
In the fixed form the imersion n complete, and onl> the first portion of
the duodenum is mobile Sandtra desenbes the radiographic features of
seven cases
JIonritoLOorcAiXi the inversion is complete, and the bulb is kinketl do^ni-
uards Variation in posture reveals that only the first part is mobile Tlie
position of the remainder is constant Tlic pylorus and duodenojejunal
flexure are situated normall^ , to the left of the midline The stomach is of the
ptosed hiTiotomo tj^pe
The fbllowing functional changes are seen a tendencj to to and fro or
pendulum mo\ ement of the contents of the loop, and stasis therein In a case
iHustrated this observer the loop showed a mild ileus
CLT^^C4.Lt,\ sjmptoms maj be present, but whether caused by the abnor
mality or bj an associated state, such as Glenarrl s disease, is uncertain *
Epigastric discomfort after food a feeling of distension, nausea, and sometimes
actual pain haie been noted, but they do not constitute a chancteristic
8j mptom complex
SITUS INVERSUS PARTIALIS, COMMUNE MESENTERIUM
In this congenital abnornnht^ , described m detail m the section on the colon,
the third part of the duodenum does not cross the midbne, and there is no
duodeno jejunal flexure underneath the superior mesenteric artetj The third
and fourth parts of the duodenum descend to the right flank to jom the jejunum,
w Inch w ith the ilcum occupies that part of the abdomen
BENIGN TUMOURS OF THE DUODENUM
Thc^ic arc rare, but not so much so as caremonm The commonest vanetics
met with are mjoma adenoma, fibroma and lipoma As they increase in size
thev maj cau'se duodenal obstruction and give the radiographic picture of
that complication Tliej tend to become pedunculated, and then produce a
mobile filling defect in the duodenum
When large and pedunculated the\ inav cause duodenal tnlitsftisceplion '
Of a senes of ten cases of intussusception collected b^ Kellogg, three were
diagnosed radiographically as simplcstenosis.malignant stenosis, and adhesions
rcsjiectn ely The last case is reportetl by lum in detail — a fibroma attached to
the duodenal wall near the pyloni*. nnd the tumour, pylorus and duodenum
invaginatcd into the jejumnn The mdiogmm showed the pylorus mvapn-
nted into the duodenum, and a filling defect from the tumour invaginatcd
into the jejunum.
ALnil.NTAR\ TRACT
no
CARCINOMA OF THE DUODENUM
Tins IS a rare cliseisc being reported to represent 2 per cent ofallpnmar}
malignant growths of the intestine It is commoncbt in the second portion
According to JioUeslon 60 per cent of eases occur in that site
Pathologically there are two types cylmdrical celled tending to produce
an nrmnlar construction and spfaeronlal-cellcd The latter type forms a flat
plaque or ft deep fungating ulcer
The Radiological Features \ar3 according to the pathological type and
the site
(1) SirpRi vMPiTT^LARi — ^Tlie symptoms are those of pjlonc carcinoma
and radiographicallj the condition is mistaken for a duodenal ulcer if the
pjloric canal is intact If the pyloric ring is mvoUed m the growth pjlonc
oifcmoma or pjloro duodenal ulcer are the conditions for which it is liahlc to
be mistaken
(2) Ampullar^ — Intermittent jaundice is an early feature A bnniiui
meal will si ow a filling defect and/or a duodenal ileus fiom obstruction b\
the lesion
(J) Infra ampillar\ — In tliesj cases there is a considerable tendency to
obstnictiso ileus Cluncallj aoiniting is a feature tlie vomit containing bile
and pancreatic fennents
Radiographically a duodenal ileus is evident and possibly a filling defect
from the obstructing growth
THE DUODENUM IN ENLARGEMENTS OF THE HEAD OF THE PANCREAS
riie duodenum shows a typical appearance m tlicse enlargements what
eaer the caufce be it carcinoma sarcoma cyst or abscess This consists in a
widening of the duodenal circle and a flattening and compression of its lumen
\s the duodenum is wvapped round three quarters of the head of the pancreas
obt lousJy any cnlai^cment of the latter will tend to spread out theduoflenalarc
and to stretch and flatten it as a tulic Gastnc stasis is a common sequela
With ton«iderable enlargements the pylonc antrum may be raised and the
duodenojejunal flexure depressed Tlie commonest type of enlargement is
carcinoma in which tondition the diagnosis is usualK settled by obstructive
jatinihcc
CHAPTER \III
THI STO’^rACH AXD DUODENTHI APTER OPERAT^O^
\ RAY EYAJtn. mON of the stomach or duodenum which has been the seat of
surgical interference frequently presents a problem of great difficnltv
In the case of the intact stomach the examination is made easy hj the
possibility of filling it out to normal contour As a rule howeier wath
tlic stomach after opcrition tins is not posaible and a wade vanetj of appear
ances may present themselves in the absence of any pathological condition
It IS the difficulty of disentangling these normal variations from the patbo
logical which constitutes the problem
TECHNIQUE
Because of the above consideration the radiographic teclwiique must bo
modified in some respects Screen examination is even more important than
in the intact stomach and the demonstration of the miieos'i] relief pattern is
of greater value
The teclmiquo must be varied acconlmg to the precise operation performed
and It IS most desirable to have this information before commencing the
examination
From a radiographic point of view these cases fall into broad classes those
III which sphinctenc control of gastric evacuation has been abolished and
those m which it has been retained Some operations fall Ijetween these two
groups as follows
(J) •^^rniMTEnic Control HtTAivEo
Simple excision or cauterisation of a gastric ulcer
W edge resection
Sleeve resection
Gastro gastrostomy
Duodeno jejunostomy
(2) Sphiscteuio Control Partlx UrrArsED
Pyloroplasty
Schoemalver s operation
Billroth I
Although in all tliese tie mujAmhr pylone sphincter is cither cut or
removed yet enough control of efllux is exhibited by the stomach to vrorraiit
tlie nlxne term m classification
1‘52
ALDIENTARY TRACI
(3) Spiunctekic Covtroe Abolished
Castro jejunostoraj (Only when abnormal contracture of the stoma ha>
tal»en place, is there anj degree of control )
Billroth U
Polja and its modifications
Finney’s pyloroplasty
In the First Group, with retention of sphmcterie control, the technicjuc
should follow that described for the intact stomacJi Special attention should,
however, be paid to the relief pattern, both under the screen and m serial
radiograms Tlie erect, supme, and prone positions arc all of value, and the
most suitable for taking radiograms will be determined by the fluoro
scopic appearances
In the Sfcond Grolp, again, where partial control has been established
the normal techmque may suffice, but means should be at hand to control
the gastric efflux, should this prove to be too rapid to allow satisfactory and
complete filling of the stomach Such means are indicated in the sue
ceeding paragraphs
It is in the Third Gbolp, with abolition of sphmctenc control, that most
difficult} occurs A vnde communication cTists between the lower part of the
stomach and the small intestine, and the gastne contents ore rapidl} poured
out into the jejunum It is impossible to distend the stomach, or stump of the
stomacli in gastrectomj, unless the efferent jejunil loop be occluded bj pres
sure This can be done by hand temporani} under the screen but this immo
bih«e8 tho palpating hand, and cannot be kept up indefimtel} borne form of
meohanicflj com})^cs’^or or truss is much to be preferred A well known type
13 the Chnoul compressor In this, a metal nng. 6 uiches m diameter, supports
a rubber bag v\bich can lie inflated to a hemisphere It is strapped to the
patients abdomen by an attaclicd broad webbiug band and buckle Pressure
on tlie required area is induced and maintained bj the inward bulge of the
bag The objections to it are (he difficult} of precise adjustment and the
shadow of the metal nng
Berg's pressure cone and scnal radiographic apparatus, although designcil
primnril} to stud} the relief mucosal pattern of stomach and duodemmi vnil
serve to control the stoma of a gastro jejunostomy Its disadvantage for the
latter is the hinnll aperture it possesses, limiting the fluoroscopic and radio
graphic field
The WTiter has designed an adjustable tnisg which answers the htter pur
jKTse — control of the eflerent loop— satisfnctonl} It consists of tw o portions — ■
a leather covered spring band similar to that of an ordinar} hernia tniss and
an adj iistable compression pad Tliree or more spring bands are nece^i.'iarv , to
fit varvnng sizes of patients Tho adjustable pad comprises a base slottcil for
the reception of one end of the appropriate spring band, an arm hinged on this
base giving, bv means of a small thumbscrew and wonn gear, an nntenor and
THE STO^^ACH A^D DUODENUM AFTER OPERATION lo 3
postenor angulation anti a leather padded aluminium pad The ami is
slotted throughout its length and the pad can be adjusted along its length h^
a butterfly nut The lunged arm has an upward bend so that the compres
Sion pad is abo\C the lei cl of the spring band when fitted to the patient Thia
avoids obscuration of the field under examination bi the shadow of the spring
Reference to the diagram -
will indicate the details f ’
of the truss (Fig lOG)
The technique for
each individual case wall iv
varj according to eir
cumstances but that 'vONv H SStjor*?
which the writer uses as \
a basis is ns follow s ~ ~ ) V
The etamination is I - ■■ —
commenced in the erect
position^ and under Pk, I 06 — Ttum comi re<sor
fluoroscopic control the
patient drinks one mouthful of the opaque cream This gives a pre
liminar} ecrccn survey of the rehef pattern of the stomach the stoma and
the efferent loop after whicli a radiogram is taken The truss is then fitted
with the spring band just beloit the iliac crests and the pad over the efferent
loop The patient then dnnka a few more mouthfuls and the pressure of the
pad IS increased bj turning the worm nut till obstruction of the loop is obtained
Sufficient of the meal is then dnmk to distend the stomach
Antero postenor sena! and left lateral radiograms are then taken and the
compressor removed Remov al of the latter is a matter of a few seconds Tlie
rate of emptjang of the stomach is then noted fluoroscopically, attention being
paid to nnj tender points over the stomach duodenum and stoma Tlie degree
of jejunal overloading if anj should be noted
In a few minutes the stomach will as anile have largely emptied itself and
enough of the cream vnJl remain therein to permit a further observance of the
mcfcosa? nsiccS pctffcrrr rn fhe prone and ntffttae poaitnm^ mas
l>o taken in these jHisitions if necessary
Tlie patient should again lie screened half or one hour later to determine
the atnount of residue m the stomach
feucli js the average technique rcqujm! in these Group III cases but the
study of each case should be individual and no cast iron routine should be
adopted in the teclinique
llefore considering the normal and pathological appearances after opention
it 18 disirahle brieflv to outline the nature of each Some of (he operations
described l>eJow are but rarelv perfomieil and still less frequently seen in nn
X rnv department Others such as postenor gastro jejuno-tomv and partial
ALDtEKTABY TR^CT
l’)4
gastroctomj are Iris <i la mode and sucli patients are frequentK referred for
A m\ investj^tion
OPERATIONS RETAINING SPHINCTERIC CONTROL
Simple Excision or Cauterisation of a lesser curve ulcer Tlie operation
reqiures no description It is rareU performed noTv Tbe radiographic appear
ances are shortemng of the lesser curve pnekenng at the site of operation and
local disturbance of the longitudinal nigai m the relief pattern (The operation
13 usualh combined with posterior gastro jejunostomy — Balfour s opention )
Wedge Resection of the Lesser Cur\e — ^This is also out of fashion because
of the tcndenc^ to recurrence Tlie radiographic appearances iho\e are
aceentuatwl Hour glass stomach is said to occur frequently after this opera
tion The resection on the lesser cor\e causes scamng and contracture on (hat
side of the stomach and the greater cune may show a spastic mcisura for a
time accentuating the biloeulation
Sleeve Resection — ^This operation consists of segmental resection of the
lesion bearing area usually m the middle portion of tbe stomach with end to
end anastomosis It is rarely performed now
A certain amount of deformity may occur at tbe suture line owing to
dispnntj m the sires of the Anastomo«c<l ends Some contneture of the
ninstomoitis usitalK takes place and shows nnbographicnllv as a notclung
of Iwth cu^^atures at the site of anastomosis This commonly gives an
hour glass appearance
This contracture does not necessanli mean that the operation has been
unsiieoessful It is compatible with a sati'factorv physiological result and
should not be regarded as of senous importance unless an ulcer crater !<« aLo
V!»ible in the region of the leswser cur>e
Tlie mucosal relief pattern is disturbed at the suture line According to
Kerht/ a temporan p\loric insiifliciencv with duodenal dumping rccuits
from the section of the nenes
Castro gastrostomy an anastomosis performetl of yore between tiie tvro
vacs of an organic hour glass stomneb It has been entu^ly superseded Tlie
radiographic appearances would be tlio«e of a double cfianne! in the stomach
with considerable irregulanty Duval reports several such cases
Ouodeno jejunostomy — -Tins is the ojieration of choice m chrome duodenal
ileus in\ohing the whole duodenum The duodenum is mobilisetl brought
through the transverse mesocolon and anastomosed laterally to the jejimam
a short distance lielow the duotleno jejunal flexure (Fig 107)
On comprn«on with rndiognims taken liefore the operation the duodenal
dilatation will be teen to hare titmmishcd or di«nppcarc<l and the opaque
mctlmm to piss through the stoma into the jejunum (Fig 10**) TIjc stoma ms\
lie hidden in the erect position h\ the atomach if the latter be ptose<l and
dihted If so the supine position will bnng it into mcw
THE STOMACH A^^) DUODEKUSt AFTER OPERATION 163
Cholecysto-gastrostomy — Tliis
operation 13 performed for complete
obstruction or destruction of tlie
common bile duct, and consists in
anastomosing the fundus of the gall
bladder to tlie anterior surface of
the pjlonc antrum Tlio radio
graphic appearance with a bnnum
meal is quite typical The gall
bladder fills Mith hanum, and m the
erect position the upper part of the
gall bladder contains an uir pocket
nbo\e the barium The cystic and
hepatic ducts may also fill, and are
prone to do so, since they are
usually to some extent dilated as a
result of the obstnictiro lesion for
irhich the operation uas performed
Cholecysto - duodenostomy — In
this a similar radiographic appear*
anco IS seen, saNe that the anosto
mosis is hetueen the fundus of (he
gall bladder and the mobiL&cd second
l>ortion of the duodenum The
connections of the viscera are then
the same as obtains m calculous
cholecysto duodenal fistula
OPERATIONS RETAINING PAR-
TIAL SPHINCTERIC CONTROL
Simple Pyloroplasty — This eon
sLsts of a longitudinal incision of the
pyloric canal, in cases of simple
pylonc stenosis the incision licing
sutured tnvnsi cicely {Fig lOO) It
IS rarely if ei'cr xierformed
nou gastro enterostomy or
Fiimey s operation being
used in Its stead The radio
grapluc contours of the
pylorus and duodenal bulb
arc grossly di-tortcd by this
Fio 108 — Nonrml appeamnee afior
«l«o«l«TO io;tino«tomj for arietta me-vnterie
<lu<Klcnal ilriK
Fro loo — iSirnpIc j jloroplaat>
ALHIEMARY TRACT
lo6
operation and unless previous informahon as to the operation were a\ailab]e
It Avould be mistaken for pj loro duodenal ulceration or scamng
Billroth 1 (knowi m France as Ptans operation) — ^Tlns is in essence a
partial gastrcctomj mtli end to end anastomosis of the cut duodenum to the
lower portion of the gastric stump
(Fig 110) The upper portion of the
gastric cut end is closed bj sutures
It IS techmcallj difficult and leaking
from the stoma is apt to occur It
18 rarely performed non Radio
graphically the stomach is seen to be
truncated and the gastric contents
to pass from its most dependent
portion into the duodenum Tlie pio no— Biirothi part at /iMitwtomv
stomach is dragged to a larying
extent to the left The degree of control of efllu^ is dependent on the amount
of contracture at the anastomosis
Kochers Operation is similar to the Billroth I escept that m it the gostnc
stump IS closed and the cut end of the duodenum is anastomosed terminally
with the postenor surface of the stomach Cuneo illustrates an e\ample in
which the radiograpliic appearance is that of a conical gastric stump with the
duodenum joined to its end The appearance is substantially the ume as in
the BiUroth I Gastric e%acwation was rapid in this c'lsc
Schoemakcr s Operation — This is a partial gastrectomy leaving a long
tongue of the greater curve to allow of an end to*end anastomosis with tic
duodenum The diagram m
^ ^ dicatcs the type of resection
^ ^ \ It is a modification of the
I y ) ) Billroth I designed to o%er
[ / ( / come the techmeal diflicultics
111 \ / of the latter It was first dc-^
/ j /’TT^ J ( scribed by Scl oemaler of The
J C(S^ J Hagueml92l amlanexcvUent
account of sixty eight cases
r,„ 1 M 1 . op™, on >■>
and Roberh (Fig 111)
The \ rav featiireofnoteincosesnftcrabchoemakeroperationisthegradu'il
rc^hlHlio ad tt legrut t in the gastric contour The food pas es more slowly out
of the stomach than m a Polya or Billroth II hut more rapidly than in the
normal stomach After six months there may be Burjin^ingly little deforniitv
of the lesser cune a rather inde pilonc nog appears and the first portion o
the iluodcmim ma\ deiclop an almost normal bulb The pylnnc antnim
naturally short and rather narrow in calibre
THE STOMACH AXD DUODENUM AFTER OPERATION 157
GROUP WITH ABOLISHED SPHiNCTERIC CONTROL
Ihis group comprises the majontj of post-operati\ e ca'ios referred for
X ray eramination, mcUiding as it does gistro jejimostomj and the popular
varieties of gastrectomj Incidcntallj it is the most difiicult group to
examine radiographically
POSTERIOR GASTRO-JEJUNOSTOMY
This IS the operation of choice for simple pyloric obstruction and duodenal
ulcer, and la probably performed more often than all the other gastric opera
tions together The essence of it is to form a wide anastomotic opening he
tuecn the jejunum ns close to the duodeno jejunal flexure as possible and the
posterior nail of the stomach (Fig 112) The anastomosis
must of necessity be made through the posterior layer of
the lc*v«cr SIC Tl«> pj}orii9 is sometimes oechtiled , this
occlusion IS often designed to be temporary, and by
suitable choice of sutures the pylorus Mill become patent
again six months after the operation
TJic objects of the operation are to pruaide free drainage
of the stomach to allou alkaline reguigitntion from the
jejunum and to prex ent t lie passage of acid gastnc contents
oxer the pyloric or duodenal ulcer
There arc certain surgical desiderata to be obserxed in
the planning of tho operation
(1) The stoma xxhen made should be -J-3i inches m length This largo
oix?ning IS cho<ien to alioxx for the considerable contraction xvluch takes place
after the operation
(2) Tile long axis of the stoma should be rongldy vertical It may mcline
either to the right or left xxithout detriment The usual inclination is from
the nght shoulder to tho left hip, for reasons of technical facility
(3) Tho loxxer end of tho stoma should l>e close to the most dependent
jiortion of the greater curxe, to prexent stasis m tho stomach beloxx tlie level of
the stoma Tins latter, hoxxexcr, occurs only if the stoma be placed xery high
(4) No more of the jejunum should bo left betHcen the duodeno jejurml
flexure and the stoma than xvjll allow an easy sxxccp doxxmwnrds on the part
of the jejunum l)ct\\ con those points Too little** cloth * xx ill produce dragging
on the flexure, x\ hilst a redundant loop may promote stasis in the proximal limb
•ToHlenor
jpjiinoytomx
NORMAL RADIOLOGICAL APPEARANCES
In the erect position the prominent fcatiiro is the immediate jiassage of the
oiwique medium into tho jejunum ^iis occurs as soon as the patient sxxalloxxs
a mouthful or so No more should lie gixen m the firefc instance, ns the initial
study of the nhef pntleni of the stomach, atomn, and jejunum is important.
158
ALTMENTABY TRACT
If then the patient takes the remainder of a 12-14 oz banum meal some
fleeting complete filling of the stomach may take place, but more tommonlj
an irregular partial filling onli is aclucaed the barium pouring into the efferent
loop of the jejunum in a steady stream (Fig 113) The greater curve above the
stoma IS frequentlj
indented b\ the mu
cosal folds resulting
from the muscular
contractilitj of the
stomach During
this stage the stoma
itself IS hidden m
the antero posterior
neiv
The pyloric an
trum distal to the
stoma rarelj fills to
un\ pvtent even if
the pylorus has not
been occluded eg J*'
a case of ducKlenal
ulcer As a rule ft
feu irregular streiks
of barium are all that
are seen in this
portion Soinetimes
tin in— Nonnal posferor (is«ro j^jiinoht im immcUiateK it is better filled ailtl
afl^r III? mrsl _ , ,
some of the bamim
cream passes through the pylonis and duodenum but even then the pyloric
antrum tends to lie conical and Jacks its normal rounded contours If the
pjlorus has been occluded the filling of the pyloric antrum is very poor indeed
Tfie stoma uiia lie seen in profile in a lateral \ leu hut for techmcal rea«on9
it may lie difficult to obtain a sharp radK^ram of it in this position
The efferent jejunal loop and the upper feu coils of jejunum are usualh
someu hat distended w ith banum and o mild permanent dilatation of the upper
jejunum is normal It may be considerable The feathery appeaniuce re
suiting from the valvulT? conmventes persists but to a less extent than in the
normal as a result of this dilatation
Ah a rule little or none of the meal passes into the afferent loop via the
stomn u ith the patient in the erect position Any banum present m it and ui
the duodenum uill usually haxe found its way through the pylorus
The rate of emptying is remarkablr rapid m the writers experience
Vnnous authonties have given the time for complete emptying as one to two
THE STOMACH AND DUODENUJI AFTER OPERATION 150
hours, and on cn more These figures maj bo true if bj “ emptying ” is meant
the complete evacuation of es er> traccofbanum from thestomach, but not if the
mam mass of barium is referred to The mam bulk of the opaque meal may have
passed out into the jejunum in ten to fifteen mmutes, and j et traces of barium
remain entangled in the mucosal folds for an hour or tuo (espeeiallj in the
folds of the pjloric antrum) Disregarding these entangled residues, the
stomach is emptj m from sc\en to thirtj minutes, if the stoma be of aicrage
8l^e With a large stoma these limits are shortened, and u ith a small one they
are mcrea’sed r
Duval and his co workers state that although there maj be rapid emptymg
for a time after the operation eicntuallj, if the operation is successful, the
stoma acquires some measure of sphinctenc control, and the rates of gastric
e\aciiation are only a little Jess than those of the average intact stomach
There is no doubt that the rat© of ev aciiation in gastro jejunostomy gradu
ally slows down with the passage of months or years To account for this by
postulating a true sphinctenc action is to attribute to the stomach n remarkable
metaplaatic power , that of growing a circular ring of muscle fibres round a
wound m its wall, and developing a reflex nervous arc to control it This
seems scarcely within the bounds of improbable possibility A more reason-
able explanation would bo the gradual contraction of the circular submucous
scar resulting from the incisions, wath consequent narrowang of the stoma
The more marked degrees of slowing of the gastric evacuation — up to
several hours — arc m most ca«es due to post ulcenitive stenosis of the stoma
The rate of empty mg of the stomach is modified l>v posture In the supine
position a pool in the fundus may remain for a time, being there below the
level of the stoma No lengthy stasis occurs however, because of the con-
tractile tonus of the stomach
As the stomach empties its contents, the mucosal pattern of and round the
stoma again makes its apjwarance, and may again lie studied fiuoroscopicallv
and m radiograms
Tenderness on pressure over the stoma and elsewhere is an important diag-
nostic feature and careful search for such tender points should always be made
If the sfomach before the operation was grossly dilated and atonic, and its
muscle coats too atrophied to be rcstorwl to the normal, the radiograpluc
picture after gastro jejunostomy will be somewhat modified Some dilatation
w ill remain, the indentations of the greater curve w ill be less and there will be
a tendency to pool formation m the pjlonc antrum lielow the stoma The
mam mass of the barium cream will, however, pass rapidly into the jejunum
Pressure Control of the Efferent Loop
It IS obvuous from the normal appearances, without control, that the demon-
stration of recurrent duodenal and pjlonc vilccr, and to a less degree lesser-
curvTs ulcer, may lie difficult on account of incomplete filling of the stomach.
160
ALDrCXTARY TRACT
Efficient obstruction of this loop enables the contrast medium to l>e dammed
back in the stomach and a study of these portions to lie made Using an
apparatus such as is described alx»c, the les&er curve can lie evammed in its
cntiretj Tlie prepj loric region is sometimes filled to jts normal contour^ but
more frequently remains to some degree contracted and conical If the
pyloric canal be not obstructed or occluded, the meal can be forced through
it into the duodenal bulb It is of importance here to knon beforehand
■whether the pylorus was occluded at the operation or whether it was already
stenosed The duodenal bulb does not usually fill out to normal contours,
jiartly because it is difficult to force a sufiBcientlv large amount of banmn
through the pylorus at a time and partl\ because some scarring of the bulb
may jiersist after the healing of a duodenal ulcer
THE COMPLICATIONS OF POSTERIOR GASTRO-JEJUhOSTOMY
Tabulated below are the normal and abnormal results in 150 consecutive
barium meal e'sammations of posterior gastro jejuno«tomy They are drawn
from the \ ray departments of two London hospitals and private practice, and
represent cases o\ierate<l on hy many diflerent surgeons That is to say thev
do not represent the surgerv of those two hospitals but rather an avemgo
sample from most of the surgical centres of London ami some of the proMiices
^O^TFRIOU OASTRO II
Normal
Dumpini; Atuina
Infl*mfi»Ator» «>qo^lp
Cit- tntis
C6b<tro lojiinitis
J«jum(u
t IrcratOC
UppuTTenl
lUvum'nt levier curvo
Tejunal
IlfpjjiTPnt po«lenor wall
Rwiirmit p> lonr
Oaatro onUro-coIic fvrtula
Slenotif fcWjurla*
StonOfi) of «« ina
Ob«tnirtioii of noma
Memo*n of efferent Ijmh
SYentHW oJ^ AlTerent fimfi
Duodenal iIea-<
lejunal ileui
rttntrBcfiire of j viono antrum
lone olenanA
Hvh inal plaroil ttoina
CareiQonia Mip«n> eninz
RetroKTa le p jiino pa«liv tntu.-iMi«r<
LJCNOSTOil^ 1 >0 CASt S
THE SIOMACH A^D DUODENITM AFTER OPERATIOJf 161
Hic number of abnormal rcsulU found bj examination exceeds con'^ider
tbK the total number of ca^es ns m man} cases more than one abnormality
vvas found e g recurrent duodenal ulcer and jejunitis
\erjfication of the abnormal results bj operation has been possible in a
small proportion of cases onl^ oumg to a insc reluctance on tbc part of sur
goons to operate on these cases a second time but the more serious of the com
plications arc only too certain rodiograplucally Amongst such maa be men
tioned recurrent ulceration and the grosser forms of stenotic sequela; In the
milder ahnonnalities such as dumping stoma slight stomal stenosis slight
gastro jcjunitis a personal factor may allow some error to creep in in differ
cntiatitio the ahnormal from the norma) but these are of little consequence
compared anth the others
Jejunal Dumping dumping stoma oi erloadmg of the jejunalloop)
Tins IS a fairly common sequeh If tho stoma be very 1 irge the flooding of
the jejunum is exaggerated ind the stomach may empty into it in two to thieo
minutes Tho patient expc nonces a dragging fullness and discomfort immedi
ately after food and the jejunum i* seen to be distended and o\erloaded
temponrih Dietetic indiscretions cither of quality or of quantity increase
tho patient s diseomfort It is reasonable to explain the symptom complex on
these mechanical grounds To what extent jejunnl overloading contributes
to the development of jejunal ulcer is a moot point and one diflicult to
put to the teat
Gastritis
The presence of this condition is diflicult to establish radiologically m the
absence of on associated jejumtis unless it is gross in degree
The commonest ty^ie is a peri anastomotic hiemoirlmgic gastritis a condi
tion frequently leading to stomal ulceration
riie difllculty lies in the increase in the rugm folds winch usually occurs in a
successful uncomplicated gastro jejunostomy so that unless the jejunum is
a! o jinpbcUcd this conditinn should be di^no^cd radiqgraphicnljv only Jf
there IS grass inrreasc in the sire of the nigm and marked spastic reaction on tJie
greater curv c
Jcjunitis
1 lie barium in a normal loop of jejunum shows a feathery or granular dis
tribution with fine subdivisions due to the valvul® conmventes In the
normal jejunum immediately distal to a gastro jejuiiostomv some nlteration in
the appoamnee results from the overloading of the gut Tl c v alv ulai conniv entes
are still clearly seen as timi knifchke interhcctions mthe hanum ma<53 Jejumtis
l^ a not uncommon sequela of gastro jejunostomy csjwcially in cases of marked
\ u It — 1 1
160
ALLMENTARY TRACT
Efficient obstruction of this loop enables tbe contrast medium to Ixjdnramctl
back in the stomach, and a studj of tlie«e portions to 1x5 made Using an
apparatus such ns w described above, the looser curve can be examined m its
entirety TIio prepjloric region is sometimes fille<l to its normal contours, but
more frequentiv remains to some degree contracted and conical If the
pylonc canal be not obstructed or occluded the meal can be forced through
It into the duodenal bulb It is of importance here to know beforehand
whether the pvlonis was occluded at the operation, or whether it was already
stenososl The duodenal bulb docs not usiialH fill out to normal contours
partiv Ixjcouse it is difficult to force a sufficiently large amount of baniim
through the pylorus at a time and partly l«cau>«c some scarring of the hull)
may iiersi't after the healing of a duodenal ulcer
THE COMPLICATIONS OF POSTERIOR CASTRO-JEJUNOSTOMY
Tahulatc<l liolow are the normal and abnormal rcsultH in 150 consecutive
harinm meal examinations of postenor gaslro jejunostomy They are drown
from the \ ray departments of two Ixindon hospitals and pnv ate practice and
represent cases operated on by many different surgeons Tint is to say they
do not represent the wirgery of those two hospitals but rather an average
sample from most of the surgical centres of London and some of the provinces
roSTmtOll C.\<?TKO ILJLNOvTOM\
\ofin*l
Dump rtj, utoiTUk
tn/liimmaton M'r|ii<<Lf
rn^tritiN
Oivitn>-ji*jtiniU«
JejitnitM
I li-**™!!*** luyiup! I
R« unmt liKxl<5nnt
llrium nt l<->«er « jir» *■
po«tfnof w»H
llwurmiit p\lnn<5
Momol
•stenotic- nec] iHv
SlenoHis of vtnnM
Ub*tnicl>oti <if iiioniA
Sleiia»w of pff fvnt Irn l»
M« n >in « f saerent Inn!
I) loclennl ileun
Jejunal iIpud
Cl ntrartiirc of pjlorw antnim
!*> I nr vtemxiit
Ku,! iiial I Ueisl Ptoma
< amn imn eiijK-neiimi:
lieir wra (i* jpjiin i gastrip intu«ni«replion
4
!tl
17
— 40
Total
THE ST05IACH AND DUODENUM AFTER OPERATION ICl
3 number of abnormal results found by examination exceeds consider-
10 total number of cases, as in man> cases more than one abnormality
|\as found c g recurrent duodenal ulcer and jejumtis
Verification of the abnormal results by operation has been po‘>3ible in a
onall proportion of cases onlj, owing to a wiaj reluctance on the part of sur-
'Cons to operate on these eases a second time, but the roorosenous of the com-
[ilications are only too certain radiographically Amongst such may be men
Cloned recurrent ulceration and the grosser forms of stenotic seqiielie In the
imlclei abnormalities, such as dumping stoma, sbght stomal stenosis, sbght
I'astro jcjumtis a personal factor may allois some error to creep m m differ-
entiating the abnormal from the normal, but these are of little consequence
compared mth the otliers
Jejunal Dumping (Syn dumping stoma overloading of the jejunal loop)
llus 13 a fairU common sequela If the stoma be verj large, tbe flooding of
the jejunum is exaggerated and the fitomacli maj emptj into it m tiro to three
minutes The patient experiences a dragging fullness and discomfort immedi-
ately after food, and tlie jejunum is seen to be distended and oicrloaded
tomporanlj Dietetic indiscretions, either of quality or of quantity increase
the patient’s discomfort It is reasonable to explain the sjmptom complex on
these mechanical grounds To what extent jejunal oxerloadmg contnbiitos
to the development of jejunal ulcer is a moot point, and one dilBcuU to
put to the test
Gastritis
The presence of tins condition is difficult to establish radiologically m the
ub'^ence of an n'ssociated jejunitw, unless it js gross in degree
The commonest tj'pe is a pen anastomotic liamiorrljagic gastritis, a condi-
tion frequently leadmg to stomal ulceration
Tlie difficulty lies in the increa«so m tlic ruga folds w hich usually occurs in a
successful uncomplicated gastro jejunostomy, so that unless the jejunum is
al«() implicated, this condition should bo diagnosed radiographically only if
there is gross increase in the sire of the nigjo and marked spastic reaction on the
greater curve
Jejunihs
The barium m a normal loop of jejunum shows a feathery or granular dis-
tribution, with fine subdivisions due to the valvulie conmventes In the
normal jejunum immcdintoly distal to a gastro jejunostomy some alteration in
t he appearance results from the o\ crloadmg of the gut The vaUnilai coumventes
arc still clearly seen as thin kmfehkc intersections m the barium mass Jejumtis
IS a not uncommon sequela ofgastro-jejunoslomy, especially in cases of marked
\ R Ti — 1 1
IC2
\L7JILNTARY TRACT
livperclilorlivclna It ma\ exist xnth or 'ttithout gastm jejunal or jejunal
ulcer, but IS an invariable accompaniment of tbe two latter The rachogmjihic
appearance is tvpical and con 1)0 rendilj pictured from an appreciation of the
pathological changes (Fig 114-llG) The jejuna! mucosa becomes h\pertmic
and mdematous and the plicTi markedh thickened The barium filled jCjunnl
f III 1 — -Di ptam to »J ott lh<’ nnli of tl jejunum an I itn I nr im fillM lumrn in (o) ll'*
normal an 1 (fr) jsjun tu
lunicii as a whole is narrowed and presents instead of the normal fuio tooth
comb serrations a scric^s of wide rounded or jagged indentations due to tic
thickened plica TIils deformitx sliows a constant contour m a scries rf
pit tiires — an important diagnostic point Icndemess on ndiosc-opit jialpstion
oxer It IS present in the great niajontx of coses
Persistent or Recurrent Peptic Uircration
lliH max 1 h gastric pxlonc diicKlenal gnstro jcjuiial or jejuna! in site
C»ASTnrc LuiP — /rsvcr-cwrie iiZrer is as n nile demonstrated if the
stomach lie ^cn>^oImb!^ wcllfillcd Itx contnilhng the cfTcrcnt Iwp a niche will
Ik. made xisihlc xvith greater cerlniiitj and on the. greater curve a local>-'*cd
exaggeration of the iiotthmg winch is usually prei'Cnt The name applies to an
ulcer on the jtasffnor unll
RronrwL Li/tr presents a more difficult problem , cxen more difficult
than ill the case of a ducxknal ulcer which has recurred after medical treatment
tio II ' — III III** <le\eIojim«’nt of onJ jijunat ulcer followmc on jxwtcnor
;rA'<tn> jcjunovlomv
Note «l*o tlio <lc\cIopincn» oflifwtni- ditirticulum near tlic runlm
lO
104
ALHIEXTARY TRACT
In the latter onl\ the defonnitj due to Kcamng has to be discounted After
jejunostoim, however, the further disturbing factor of incomplete or non
filling of the cap must be taken into account In some coses the actual ulcer
crater maj lie ‘leen, but more freqnenth only some general deformitj of the
duodenal bulb is present
If tlic jejunum has licen satisfactonlj occluded bj a tnis-> and food is
passing frceh through the p\lonis the second disturbing factor can be
etcluded, and tlic
problem becomes
that already de-
scribed under the
section of dnoflcnal
ulcer
Pxxopre Ulcep
IS readily demon
strated, proi ided
opaque food nn lie
nnde to pa*.-. Ibroiigh
the ptlonc canal
Gastbo JEriNtt
XlLCi-n — If the
stoma on the pe*
tenor uall is hidden
in the postero
anterior view, a
stomal ulcer mat
sliow onl^ in a relief
pattern radiogram
Frequentlj, how
ever, associated
spasm and cicntncial
contracture bnng the nna»tomosis into profile m the jxistero antenor view, and
so render > isible an ulcer in this situation If it lie large it maj be a isible in
profile in a lateral ^ lew Owing to the normal irreguIariU in the contours m a
hcaltha stoma care must be u&cdm diagnosing an ulcer crater from a projecting
nigal crci ice Furtiicr confirroatotj signs may help The most inijxirtant of
tbe^e js pain on pretvsure locaksciJ over the stoma Another sign of value H a
jKn«istent residue in tlie ulcer crater after the stomach is emptj *'Ufh »
residue must, however, Iw difrercnliatcd from flecks entangled in the mucosal
folds in this region
jFJCNAt, Uf-ciP — If this he close to the stoma, the aboie remarks will
appU If it occur liclow the level of the greater curve there is everv
chance of the ulcer crater lieing outlined at some stage of the examination
THi: STOAIACH \XD DUODEVUM AJTLU OPERATION 105
Agnm care must be taken fiot to
injitaken fleck of bamimentanglcd
m the mxitosa for a barmm filled
crater The larger, the den«ter
and the more persistent a residue,
the more likely it is to be in an
nicer crater (Fjgs 31 7-1 18) Asm
ulcer craters clseuhcre m the
ahmentarj canal, the absence of
peristalsis in the crater promotes
ecdimenfatjon of barium in it and
so causes a dense opicitj tlierem
Locnh‘'cd tenderness to pressure
of one finger over the regiduc is an
important confirmatorj sign Tlie
\aivul'e conm\eutc3 seen m relief
iwttern conrerge to and arc
interrupted bj the crater, an
appearance l>est seen if the latter
13 on the nntenor or posterior nil
and BO newed cn face An ns^o
ciated jejunitis is almost alon>«
present, and in the absence of this
great reserte should be excrci e<l in
diagnosing stomal or jejunal ulcer
OaSTRO JEJtTNO COLIC FfSTCUl
]s a not uncommon complication
of jejunal ulcer, resulting from
perforation of the ulcer into the
transiersc colon It is descriljcd m
the section on the stomach (Fig
119 )
Nanovring of the Stoma
The usual surgical practice nowo
da\s IS to make a inile stoma to
allow for gradual contraction If
this contraction i» greater than
usual the rate of gastric e\atuntion
IS sloweil To what extent this
narrowing and consequent slow mg ib
(lisa<l\ antngcous is a mat ter of doubt
The wide stoma, while it achio'Cs
t-fo 117 — AD I ulrcr folJowuiff
p<>»t«*nor (iMlro j<-iunostom\
ttr IIS — ra,*lroi<'jun)tt« An 1 ;p;una] wJivr
rollowinu pcKicnor
ICC
ALniENTARY IRACT
its results <10 far as drainage is concerned, alters the normal iilijsiolof'iral
processes profourulh, and frequently caascs jejunal overloading Narrow
ing of the stomach sufficient to slow the rate of emptjiiig of the stomach
to liotween one and
I ' ■ one and a half hours
is prolnbli not un
de«irable but reton
, / tion m the stomach
up to two three or
more hours should !«
regarded ns a sequela
hkelv to defeat the
objects of the ojiera
tion In bitcii oases
the stenosis of the
stoma cannot usuallv
be demonstrated
ilircctJj In the
majoritj of cases its
presence can be
deduced onij b\ the
slow rate of emptying
kSomc contractwn
of the stoma after a
year or so is a normal
occurrence but the
common caiiBC of
maikcd narrowing of
the fetomn is cicatri<ss
tion after ulceration
This produces van
l-ir 11(1 ( -V'tni l^jiino iistiilA <iimon.'-trut<sl >i> a
I urium oriciiui n cf j jcjunosloim
an I jojunat uU-cmtiuii
ing appearances
according to the
o\nct Kite of the
stenosis Yvefmwcc
to the diagram (Fig !20) indicates the possibilities m this rcsjicct
No 1 lleprc-entH the normal
Xo 2 ‘'tcnosis of the stoma, tho pylorus and jejunal loop remaining
patent (Sastric evacviation taken place as in tlio intact stomach, Ma tin
pvlonis and duodenum Some puckenng in tho region of tlie stoma r
usuallv present
Xo 3 Stenosis of pvlonis and stoma This results m gastric dilatntior
and sta-siH
THE STO^IACH AXD DUODEXUai AFTER OPERATIOX 1G7
Xo. 4. Stcno^l? of the stoma and afTcreni jejunal hmb. A^ a result of
this, gastric dilatation and stasis tnhe place, and, in addition, duotienal ileus.
No 3. Stenosis of the efferent jejnnal hmb alone. Hie results are pre-
cisely the same as in No. 4
No. 0. Steno«is of the afferent jejunal limb alone Gastric evacuation
1 2 3
Fio 120— Ttie Htcnotii' coinplitatiotv* of ixwienor p«.<tro.j«-jvuio«torn>. For th** saV(* of clantj
the MOOTA u fhovrn on tho luarpin of the stomach
J Xortnal S OlMjfiJftwn of uXomu 3 Ob~tfUel«wi of p» Jorut ami utoma 4 OMnction of
Ktonmnnd Bnercnl liinb Olotrurtionofcnetent Umb 0 Olj«trtiction of afferent limbonlr
occui> through the stoma ns in a normal paslro-jejunostomy. If any appreci-
able amount of foo<l through the pjlonts, duotienal ileus may result.
Contracture of the Pjlorlc Antrum
The p\Iorio antrum u-iUaUy asanmes a more or Ic'vs conical shape after
ga»>lrf>-jejunostomy. Thi-* may lx* rrganletl as the rc>ult of disuse. 3Inrked
16S
ALIAIENTARY TRACT
contracture, narrowing the lumen down to the thickness of a lead pencil may
result from spasm interstitial fibrosis, and epigastric adhesions In the&e ca'«s
it may lie impossible, excejit by laparotomy, to exclude the pre«cnc-o of a super
venuig carcinoma particularly if an'emia ncblorhydria, and anore\n are
present as they «>ometimes are
Malposition of the Stoma
It IS only when this is gross that serious tonsequenees result Minor \arm
tions in the site of the stoma are of no importance If however tliestomaia
Vin 121 — ro«tmoT ga*ln> jijuno l€»nj will* Vit. 12' — Old paairo jejiii wVoim for uiio
ol«tru ttOH of llip (itama on 1 p} lonM Caii(rc<' alnuU ul cr wjUi ewnowH of the stom* #r>
ta^iA ohsiructi'o h>{ rrjHTutsUiH an I f.a,ttnc aflrwiC jepinal lim> recurrent «1 loilenal ul rr
litasw are rlmracteri.MK' featurca ga«tn(H an»l oWnioli'e ilf ii< of tlie daodenui’'
\cr\ high in the stomach satisfactory drainage ma\ not occur and the object of
the opemtion be not achiev ed TIic writer has met one siicii case The gastric
stasis present in this case was obviated by jiostiire when the patient lav down
the stomach emptied satisfactorily
Ducxlcnal ileus innv result in a minor degree from a high stonn csj)ecia!lv if
a visceroptosis of some degree lie present In such case if the diicalcnum and
diiodeno jejuinl llexuro be ptosecl Ixlow the level of the stoma the stomach
may empty itself partly intothennerentjejunalloop andsointothediwlciium
This sequence of events is visible flaoro«copieally On the patient svrnllow
THE STO’NIACH AXD DUODENUM AFTER OPERATION IGO
iftg a mouthful of hanuni, some is seen to pass into each loop of the jejunum,
that going into the nlTercDt collecting m a pool m the dependent part of the
ddated duodenum This is seen onlj m the erect position The supme or prone
position removes the static factor mIucIi is the essence of the abnormahtj
Retrograde Jejuno>gastrie Intussusception
Tins IS a mre complication of gastrojejunostomy It may be acute or
chronic The acute cases, of which the records of thirtj five cases havebeen
tio Ii3 — I’O'Unor giutm j»juno«l<nn% betwwn tin* Innh and Hip upper
follow M s(ono«-< of the* slonw awl p*rt of llio stonwoh TJ»p n»aJ paA««l oi« of
alTercnt limU and inarkwl «h»o lower iitomn »ip t«> llio tJpjwr, an I back
(lerinl mjj, j},,, fttoinnch again
collected bj Adams arc urgent surgical emergencies, precluding anv radio-
logical investigation
Ltdoiar Lebarrl flti<l t7ffWcfo« note the \ ray appearances m
two thronie cases Ihe intussusception produced a mobile rounded filling-
defect and the relief pattern of the tumour showed stnations due to the
jejunal plica*
The WTitcr has seen two cases of mtemnttcnt jejuno gastric intussusception
rhowing these sipis In one tho tatnour was seen end-on, and the stria?
circular m disposition (Fig 12'5) At operation the mtusnuscoptiou had
170
ALnrEVTARY TRACT
reduced itself and onlv a dilated
jejunum Mas found The second
lia*! not been operated upon
Anterior Gastro Jejunostomy
In tlus a Ions loop of jejunum
IS brought up m front of the
transaerje colon and anastomosed
to the anterior gastnc wall (Iig
12C) It IS performed faute de
mieux uhen a gastro-enterostomy
13 essential and it is tochmcallv
impossible to adopt the jK^lerior
method The stoma is made os
near as possible to the pjlorus and
greater cur\c and its axis should
run from above dominnrd and
to the right Because of the
serious nsb of stasts m the long
afferent loop— -about IS inches in
length ns a rule — an additional
jojuno jejunostomj is frequentiv
made between the two loops
The X ray oppearancei w
anterior gastro jejunostomj are
substantmllj the same os those
in the posterior operation except that m the lateral \ie\v tho stoma and
jejunal loop art M-ible anterior to the stomach and two jejunal limbs afferent
ami efferent are often outiuicil Iwlow the stomach If
the operation be successful oiih the efferent loop should
fill but frecpicnth food also passes into the afferent
^\ hen this occurs to excess a \ laous circle is established
and the dilated oaerloaded proximal loop is at once
ajiparent ra<liogra]iliicallj lejiino jejunostomj com
pletcK relies es the condition but short circuits the
alhahnc duotlenal juice from the stoma and so promotes
the fonnation of anastomotic and jejunal ulcer
The other untowanl sequclsj of antenor gastro jejun
ostonn are similar to those in tho postonor inetliod
Finneys Pyloroplasty
This operation 13 not much u-od m thi-s TOuntrx Jt is f,o joo— X nit-n r
perfonned m cases of pa lone and jtixta palnnc duodenal fciwtro j |una tomj
fio l"!— Clronic rctrogrs (v
int ■MiiM'rpt on Totlowms l o^tenor pa tro
jojuno lotnc
THE STO’NIACH i\ND DUODENUM ATHEll OPERATION 171
ulcer The second portion of the duodenum is mobilised and anastomosed
with the anterior Avail of the stomach, close to the greater curve in the
pjlonc third The
stoma runs into and
includes the p\ lone
canal and the ulcer
and «car tissue are
exci'^cd if possible
(Fig 127) In thcors Fio U" — Fmn j ap^loropliutv
the operation is n good
one as it allows free drainage and acid neutralisation
liadiologtcally tlie meal is seen to piss frecH into the duodenum no pyloric
cinil or duodenal bulb being present The junction of pjloric antrum and
duodenum !■» as a nde markedly irregular in contour The nte of ga-tne
evacuation is not so rapid as in the average gastro jejnnostomv
■Mnrgnm! ulcer is slid to be *i rare sequela, hut some cases develop
adhesions dragging the stoma up to the liver and nece^sitatmii siibHcquent
gastro jejunu-stomv
BILLROTH 11 PARTIAL GASTRECTOMY
In tlie iwst a popular operation for carcinomi of the stomach or large
chronio ulcer* in the region of the lessor curve tins operation is to some extent
being snpeweded h) the Polj a Ijpes of gistrectom> It consists of segmental
resection of the stomach mcludiiig
the p>lorjc canal closure of both ends,
and posterior gastro jejunostom> {tig
12S)
Iladtologicallt/ the stomach Iwlnves
similarly to the jcjunnstomised
stomach save that the pyloric antrum
Is ab'»ent \t first the gastric stump is
.sctojoU lu’J JsJa'" At .sncue.w.Utij
Tills dilatation is not marked unless
I-it) ij>— Billroth It I artiai pa. trefioiw^ contracturo of the stoma takes place
Tlie right bUnd extremity of the stomach
a'^sumes a rounded shghtlv jmckeretl contour The stump can Ixjst be seen if
the efferent jejunal loop bo ob'-tructed hj n tnws Onlv then can the stump l>e
proiwrlv fiUtHl and its contours studied
NonualK there is no reflux from the stomach into the afferent loop and
duodenum But efficient obstruction of the efferent loop bv a tnis* will cau->o
Mich reflux an appearance which must not be mistaken for a vicious circle
It di«v]»peirs on removal of the truss
172
ALDIEXTAEY TRACT
CotnpUcations of the Billroth 11 Gastrectomy
RtcxTRRENT Gastpic, Stomai^ OK Jejora^ Ulclr is less common than in
gastro jejunostomy, as a considerable proportion of the en^jiue-proflucing
mucosa is removed by tlic operation The more complete the gastrectomi,
the less chance of recurrent peptic ulcer Aft, howcACt, tins operation does
not allow of a verj wide resection, recurrent ulceration does octnsionalK recur,
and its radiographic demonstration and appearances are similar to those m
gastro jejunostomj
Cases oi CAnci>OMA VirNTMCUu, local recurrence of the growth not
uncommonly met nith Depending on Ibo precise site of the recnrrcncc,
there maj result
(1) ObiimcUon of th6 Whole Stoma — ^TIiis causes dilatation of the fundus
and ccsojihogus, and, clmicnllj , vomiting and rapid starvation Tlie nature of
the condition is clearly visible on fluoroscopy' and the detmU of the gastric
filling defect m serial radiograms Discounting the distortion due to the
suture line, a recurrence causing the above interference vnlh the stoma umslJy
presents a constant filbng defect vUiicIi is fairlv chnrnctcnj.tic
(2) Ohslruclton of the Efferent Loop yJ/one— Tlic stomncli vull prewnt
fiimilar appearances but m addition the duoxlenum will bo m a state of ileu«,
and 1)0 outlined by the bsruim cream passing from the afferent limb into it
(3) OOstrwliou of the Afferent Ixtop Alone — ^Agnm a duodenal ileus result*,
but ns no banum can pass intoit it will lie demonstrable radiograpliieallv only
if it contain gas
THE POLYA PARTIAL GASTRECTOMY
Polja-Moynihan Partial Gastrectomy {Stjn Autenor loft right Polya)
-~1 Ins modification of the original l^olya o|>cnition is probably more frequently
adopted m this country
than any otlier form of
partial gastrectomy It
consists of a segmental
resection of the lesion
beanng jiortion of the
stomach, including the
pylonis, ns m the Billroth
If, with end to side anas
tomosH of the gastric
stump to a loop of
jejunum In the original
J|*1 l.’a— Ant.nor L -* K r.J»»MoMulftn Polya the jejunum was
brought up through a
fenestra in the trans\cr>>e moocolon This is sod to have the disadvantage
in cases of cartmouia that ii recurrence, apt to take place near the fenestra.
THE STOMACH AND DUODEXmi AITER OPERATIOV 173
ma\ cnu'ic obstruction of the jejunum It is a\oided bv the llorni
ban modification, in which a loop of jejunum is carried up in front of the trans
veise colon Fig 129 indicates the direction of the jejunal current (from
left to right) Tim loop is chosen ns near to the diiodeno jejunal flexure as
possible allowing enough length
in the nfierent limb to preaent
nn\ pos'sibilitj of tension on it
when the patient assumes the
erect position
PoJya-BaJfour — In Balfour s
modification the long jejunal
loop IS u»cd and the jejunal
current is m the reaor^e diret
tion to that in the I^olj-a
Mojmhnn In order to prevent
stasis in the proximal limb a
lateral anastomosis is made
between the two bmbs of the
loop (Fig 131)
Modified Polja, with Entero«nna$tomosis lo Y — In this modification a
segmental re-'Cction is made ns before A jejunal loop i-s brought up as in the
PoUq Balfour, but is
fjo ni— AnlMor n
trwtonn with lonK
I 1 plv» Ilalfour partiul
inal loop an I ontcro
tlmded across The out
end of the distal limb is
clo«ed and that hmb
ann'^tomosed side to end
with the gnstne stumjj
The proximal jejunal
limb 13 then anastomosed
end to side w it h the distal
hmb an inch or t w o lielow
the gastnt anastomosis
{Fig 130)
X-ray Appearances in
the Poij'a-Moynihan
Partial Castrectom}
The gnstne stump is
as a rule smaller than in
the Billroth II operation,
and the nnastonio-'is is seen to be icnmnal To studj the full contoiirb of the
stump control of the plTcrcnt loop will lie nece>sar\, but this should be
pncodwl b\ observation of the normal emptying (le without control)
174
ALntE^TAR\ TRACT
Under tlie screen cnreful note sliould be made of the efilux info the jejunum
The barium should be 'leen to p-\ss clueflj into t!ie efferent hmb at the right of
the stump Some mil pass into the left or afferent limb but this should not
be exccssnc
ith control of the efferent hmb the fundus of the stomach should fill out
to a normal contour and there maj }>e some cesophagcal rcllu\ The afferent
jejunal hmb mil fill more dcfinitelj and actiie pcnstalsis mil be seen as this
loop endcai ours to emptt itself The contours in the region of the anastomo'is
\ar\ considerablj depending on the prccLsc position of the suture A
certain amount of puckering is to be expected
The stomach after this oiieration empties very rapidlj bj the time the
patient has finished drinking n 12 02 meal most of it mil be in the jejunum and
mild jejunal overloading is a common effect of rapid ingestion Occssionalh
it maj lie marked causing a sensation of fullness and drag^ng in the nl domeii
It IS therefore important that a patient should masticate thoroughl} and eat
and drink sloxdy after having been anbjccled to this type of operation
liaitlin Pendergrass Johnston and Ilodes in a paper stroking the effect
of different fooilstuffs on the rate of gastric eaacuation state that this obtained
also in the stomach after a Polya gastrectomy and that marked dehy can
occur after ingestion of fats even if the stoma is large Such sloiving of the
rateoFoiucuationasoccursw the result of dlmlnl^hed gastric toneand pen tali*
hut m the miler « experience the effect of gra\ ity and the fact that the Ixittom
hashtcrallv been cut out of the stomach result in rapid evacuation exenuhea
the contrast meil does contain uirbohidrotes and fats
Abnormal After>resulU
Rrci URENT Ptmc Uu tii —This an uncommon sequela may be gastric
stomal or jejunal m Mte The more complete the gastrectomi the rarer is
such a complication Recurrent gastric ulcer may be on the lesser curve when
itmllsiion asanuhe oronthepostenorwall Inthelnttercncearehefpicturc
IS the best means of domonstratiiig it
^tomnl nl(cr is more easih demonstrable after the PoKa t\pe of ojicntiou
ns the stoma is terminal relotne to the stomach As aitli other forms of
stoma residues entangled in puckcrwl mucosa must be differentiated fnmi a
Iwirmm filled ulcer < r \lcr The latter art. more lonstant m a senes of jncturcs
nn<l if tlic ulcer be deep denser from MMlimentation therein rcndenic*«.s on
locnliHcd I rcs-sure over the snsjict ted shadow is an important confinnntors si^n
lojtmnl ulcer is more readily a biblc than in cases of gnstrn enterostoma a’
the gastric shadow is not Bupenmposed on the jutta stomal portion
ONTuix-iMiTstJ OF THE pROxiMAE IJMR — lhas rarely occurs m the Pol\a
Moanilnn ojioration if the afferent jtjunnl limb be short and the axis of tie
stoma proporh planned but with a vertically disposed stoma and an unduly
long hmb some stasw and ileus may Ik seen It docs howiier occur m
THE STO'MACH A^D DUODPNtTM AITER OPER iTIO\ 17^
RFCUnnFNT CAncrvoJiA if the efferent limb be ob&tnictcd bj the recur
renco Clmicalli such cases; present characteristic features — I^ablht^ to eat
or drink any but small amounts persistent vomiting epigastric pain and
nastmg Rndiograjducallj a gistnc filling defect near the efftrent stoma mas
be prc'jcnt Q-sophagenl reflux anti dilatation ma^ occur and the meal is
seen to distend the afierent limb
(Fig 1 32) The rate of gastric c\ aciin
tion IS slow unless bj ^omltlng
Recurrent carcinoma of the gastnc
stump itself IS apt to cause stenosis at
or just above the stoma Chmcall^
the symptoms are as above described
and radiograpliicallj a considemble
filling defect of the stump woll be
apparent
Scarring from recurrent simple
ulceration maj also cause obstruction
of the stoma or either jejunal limb
cfTorcntorafreront withsimilarappcar
ances to those in the carcinomatous
varictj save tint there will not be
present a gross filling defect of the
stump itself
X ray Appearances m the Polya Balfour
and Polya in Y Operations
The appearances will vary from
those above described chieflj in the
site of tlic oflertnt jejunal limb which
IS situated at the left angle of the
stump In the IJilfoiir modification
some banum mnj pass into the afferent loop but this can ciuee no trouble
because of the jojuno jejunostom> below In the m Y tjjw again no over
loading of tl o alTerent Iiinb can occur ^\lth those exceptions the abnormal
nftcr-clTcets are similar to tho c descnlicd ui the case of the I’olja ^^ovmhan
POLYA ^VITH RESTRICTED STOMA POLYA LAKE POLYA-FINSTERER
The Polja-Lake modification judging b^ the rndiognpliic appearance con
trols the efflux of tlie gastric contents lictterthnri nnv other of the Poija tvpe
In addition to preventing dumping into tlie jcpinum it renders reflux into
the cfTcrtnt loop verv improbable
In It a short jcjuinl loop is brought up through tho transver^ mo«ocolon
tl c jejunal current flownng from right to left Although the jejunal loop is
Fjo J3 ~\ n-*I>antenor to) a pArf a!
castrreton v for can. noma w tl rot trence
obslnct n;;tl celTcrent jej nnllunb anl Iciu
of tlK> affcronl
17G
ALTAIEVTAR^ TRACT
•sutiirod aloiijT the whole length of the cut gastnc stump onlv a small stoma
about U inches m length is made at the lower end (Tig 133)
Fk. 133— Thr Pal\alAVe part at }t«L irrct«>m> (i) Tip on (*>) T1 p ana tonicw-
(p) Tire racbograpl c opj>PiuT»npp
Finstcrer s modification 15 m essence the same
Radtoiocicsl rEATUKBs — Tlic ga. tnc stump fills reasonabh well m tie
(ir 134^ — Norma] ruLagrapho appearan »
aftpr (bo ] olrs Lakof art al gastrtetom^
erect iHWition and the stoma is clearh seen at the lower pole Tlie n"l t
bonier of the stump is fonnetl bj the remaining portion of the lesser carve and
THE SIOMACH AND DUODEXU’M AFTER OPERATION 177
the sutured end of the stmnp above the stoma This largely lose'’ its initial
anguHntj and becomes more or less straightened out At the junction of the
two there is apt to remain a dimple which must not be mistakenlorarecurrent
lesser tur\ e ulcer The greater cui^ e of the «tiimp balloons out to form quite a
respectable lower pole (big 134)
Jicciinent injlatmnalory and tdcera/ite sequela: are verj rare after this
operation Lafe found three cases of jejunal ulcer in 300 patients subjected to
the operation
The \aluablc feature of this operation is the restriction of the size of the
stoma Avhioh leads to gradual expansion of the gastric stump and the forma
tion of a satisfactorj gastric rcsenoir
The position which the suture Ime Assumes after the operation {it forms
\ irtuallj a now lesser curve) is of importance in the technique The anastomosis
must be of the right — >■ left sanetj The efiect of the stoma restriction
m p^c^entlng rcflu\ into the alfercnt limb has precisely the reverse effect
if t)io stoma K restricted in a left — >-nght anterior Volya 'Mojnnhan In this
ca«o the gastric contents are inevitable shot into the afferent limb and a
\icious circle results
COMPLETE GASTRECTOMY (MOYNIHAN)
LW.«. Vv'tViw.sw.y.i , w/1 Wj •sw ?v’p'j'yrcvin\M;
immediate mortnlit> , is indicated in some cases of gross scirrhous carcinoma of
the leather bottle tape It consists of resection of the whole stomach and end
m side or side to side anastomosis of the lower end of the oecopliagus with a
high loop of jejunum The latter is brought up through a fenestra in the
transicp-c mesocolon ^lie two limbs of the jejunum maji Ito anastomosed
lower down to short circuit the bile and pancreatic secretions (Fig 13")
Earl> X-ray Appearances after Complete Gastrectomy
Of two cases examined by the wnter one was jxirformcd accor’ the
abo\o technique In it, one month after the ojicmtion the anasto
xn n— 12
17S
ALOfEXTARV TRACT
Ind alreudv begnn to dilate and to form a p>eiido fundils (Fig I3C) Iti tho
other case tlie cut end of the asophigus was anastomosed to the pjlono
antrum close to the pyloric canal A month after the resection the lower
crsophagus had begun to dilate and take o\er the duties of rc^enoir
\n interesting point m the second case was that the p^lonis remained
wideh open, doubtless from the destruction of its sphincteno reflex nerioin
control
(io 130 — \p)>earai>(^ uf the anaatomo^i’i
«nc irxmtli nfttr cotn[>k>(«> i;a.sirp<.toni>
Late X-ray Appearances after Complete Gastrectomy
liitiler Ins dcscrilwd tlic appearances m a case six months after coioplcf®
gastrectomy Ihc feature in it was a coiisideroblo dilatation of the jejunum
<lo«c to the oesophageal etonin TIio dilated portion >va.s ballooned into the
left dome of the diaphragm lontnincil a gas bubble, and simuhted the fundus
of a norma! stomach Doubtless tlie constant upward pressure of gas in this
loop contributed to this cfTcct Baniim remained m this dilated p>ciido
fundus for mon than fir e minutes At the end of an hour all the baniiin ha'
accumulated in the jiehie coils of the ilcum Transit is therefore rapid, a-s in
the partial gastrectomy ca«cs
CHAPTER \l\
THE DUPHUAGM
Iv Tins section the diapliragm in relation to the abdomen uill be considered
Anatom) — ^^riic (haphragm a dome shaped musculo aponeurotic partition
bctucen the thoracic and abdominal ca\itics is composed of a central trefoil
Hhaped tendon, and suiToundmg it a jicnpheral sheet of radiating muscular
fibres The muscular fibres are all inserted into the centril tendon, and take
tbcir origin from the follouang points
(1) Anteriorly b\ tno flesh) slips from the back of tlio cnsiforra cartilage
(2) On eitlier side from tlie nlw and costal cartilages, mterdigitatmg with
tlie transrersalis abdominis
(3) Postcro latcrall) from aponeurotic arches the ligamcnta arcuata
(4) Posteriori) from the lumlMir vertebra by tuo crun Theso crurx arch
ov er the aorta to form tlie aortic opening decussate and eeparato to form the
msoplingeal opening , and then fuse inth the central tendon
On each side there arc tuo gap» in the diaphragmatic attachment of
importance m diaphragmatic hemne — the foramen of Alorgagm between the
sternal and costal attachments and the costo lumbar angle the site of the
embr)onic pleiiro peritoneal hiatus
The diaphragm prc‘>ents three innm openings Tuo have alread) 1)ccn
mentioned both again of importance as hernial bites The third the foramen
for the Ulterior vena cava, pierces the central tendon m front and to the right
of the oesophageal opening
iNFFRion RtL.VTiON'imrs — ^Tho right dome of the diaphrigm is accuratcl)
moulcled over the convex surface of the right lolw of the liver, the right kidne)
and the right suprarciinl capsule, the left dome over the left lobe of the
liier, the gastric fundus the spleen tho left kidnev and left 6tii>rarcnal
capsule
NORMAL RADIOLOGICAL APPEARANCE OF THE DIAPHRAGM
'I be domes of tlio diaplirngm appear in a jiostero anterior radiogram or on
fliiorosoopv as smooth rounded contours stretching from the cardiac shadow
to the ribb laterilK The junction with the cardiac shadou is at about a righto
angle *^nictiincs the angle is a httic more obtuse sometime^ more acute
Ibe <osto phrenic angles latcrall) are clear cut and verv acute in evpira
tmn The) open up hut remain pointed on forced inspiration
rrcqiicntlv the domes show a shghtU wavv contour, due to the
nuisciilar hands of the diaphragm produang shallow ndj,o-'
180
ALIMENTARI TRACT
Tlie riglit dome is usualh about a centimetre higher tlinn the left due (o
the latter mass of the right lobe of the lircr
Mo\emcnts of the Diaphragm — The respirator} excursion of the diaphragm
during quiet breathing is 1-2 cm In forced respiration it may be 2 f cm
or more It is greater in abdominal breathing than m thoracic \icttcd in
the postero anterior plane the descent of the diaphragm is seen to consist of
n loucring of the central tendon to *!ome extent while the two domes as
tliej descend become flattenwl and thus show a greater range of movement
than docs the central tendon flie latter is to some extent anchored bj the
heart and pencaKlium
In the lateral a len the jiosterior attachment of the diaphragm is seen to be
about 3 inches Ixilou the anterior The anterior portion beneath the heart
IS roughl} horizontal and the diaphragm slopes dowi mcreasmglj ns it is
traced backwards The posterior part shows a greater respirator} travel than
the anterior
IRREGULARITIES IN THE DIAPHRAGMATIC CONTOUR
The commonest is upward displacement of one or both domes Upwanl
displacement of the whole diaphragm occurs from an} mcreave in the intm
abdominal tension T}mpamtes from an} acute illneas 1ms this result la
ascites it occurs to a marked degree I*regnancy large ovarian C}8t8 or
indeed an} large abdominal tumour will cause it
Upward Displacement of One Dome — ^The causes of this are man}—
introthoracic diaphragmatic and intra abdominal The intrathoracic causes
are dealt with in tfieir appropriate sections
Of the diaphragmatic and ab<Ionimal causes the following call for mention
(1) Diaphragmatic hernia Tins although not a true upward dLspheement
raises the radiographic contour and is convenient!} grouped here
(2) Phrenic nerve paral}8i8
(3) Eventration
(4) Tomporor} distension of the gastric fundus b} air
(5) Subphreme abscess
(I ) Subhcpatic ab&ces>.s
(7) Lnlargcmont of either lolxi of the hver from neoplism Iivtr al scc-'S
h\datidc}st etc
(8) Gross enlargement of the hplcen
(9) Laige renal tumour which raises the posterior part of tlie diapbra?®
DIAPHRAGMATIC HERNIA
Embr) ology
lor a projwr understanding of the eongenital t}|)cs of diaphragmatic
hernia some appreiiation of the development of that structure is necessnr}
In the carlv embrvo the pleural envnties jirotrusions of the jinmitirc
THE DIAPHRAGM
ISl
cffilom, communicate frcci) with the penloneal ciMt^ The diapliragm 11111011
cvcntuallj separates them 13 a composite structure embryologicallv (Fig 137)
The lentral half is formed from the septum transiersum, a me‘«odermtc
partition separating the heart from the abdominal nscera It first lies ohhquelj
in the neck, but graduallj moves doivn and assumes a trousierse disposition
It reaches its final position opposite the leicl of the 12th nb at about the fourth
week In its descent it carries with it its nerve suppli from C 3, 4, and 5
tlie pliremc nene The ixnnt of entry of the latter into the adult diaphragm
marks the posterior hmit of the portion formed from this septum
Tlio posterior half of the diaphragm is formed from three structures the
primitiie mc«cntcrj oftheforegut stretching
belli ecn the dorsal cmlomic nail behind and
the septum transversum in front , and the
plcuro peritoneal folds, one gromng innards
from each lateral ccclomic nail to fuse with
the septum transversum and the medial
mesenterj TI10 last portion to fuse is the
Iiostero lateral, nhcrc fora time there persists
on each side, the plcuro porUoncal canal or
hiatus Failure of this hiatus to eloso accounts
for a common t>pc of herma
Classification
The following classification is adapted from
llumt Bj the term congomtal is meant anj
hernia which occura througli a region of the
diaphragm iihero there is a dciclopmental
hiatus or 11 caknc<ss ic in cases where there is a <‘ompon»>nt--( whi h form tie ita
acvclopmcnlalc'sjilaimtwn forthemtcortlic '"'["''Xrta » ffiwitas,.. 3 Ve
horniatlOll dial mi'S’nterj 4 Inf«nof \eim
raia *» riitiro pf»nfonPnl frjId-<
CONOl’iITAL 0 Septum tnin'<\Pr>mm
(1) Through the plcuro pentoneal hmtii:s
(2) Through the dome
(3) Para cesopliagcaf (a) Through the hiatus (&) Tlioraeic stomncli
(c) Non deiclopmont of crura
(4) Through the foramen of Morgagni
AcqxTXTirv
(5) Xon traumatic
(G) Traumatic (i e resulting from wounds)
Anatomical Features
(I) HtRvii T/moLoir Tiir P/rtROPrurroNiUL HriTcs — This hiatus is
patent for the first three months of fcctal life It is situated Iwtwecn the costal
>10 137— Dacmm fehonin^ tin
182
ALDICNTARl TRACT
and spinal muscle fibres At birth a fibrou? area marLs its site — the lumbo
costal trnngle clo'je to the nrctiatc hgament All stages of hiatal defect raaj"
exist from a small gap to almost complete absence of that half of the diaphragm
It IS usualh incompatible with life as herniation takes place wl eii breathing b
established and strangulation or paralytic ileits supenenes in a few hours or
h 13H— Cor4,fit4l Jcnia of tir mo aeh Fio I3J— llfm ton of !»«' * ara»f^
tlr u"! a Uri, ri.lt j Ii'urt>-ponloni*al 1 «lU'» Jl rouRh iho ru.ht inm of tl p di»pl
(cmab J month &rln ttnl to loi<ptal ir th
Iron I [ nn ntonui nnd nt^rm tirai atlBP|>’> of
\oiml n{;
Nt pout morto n lly toma h wiw n tb" nsht
ll oras I t *1 ) ] <sl book nto tl <• alxlo ion Th t
oij In n«l Iho ntprm ttmt t ra I nji Tbf><rM>phitKt *
wna n t i>hnrlm<sl
dajs Tlif^e cases do nit n» a rule find their wa\ into an \ raj department
k plain ridiogrim of the chest ina^ indicate the nature of the condition '
the presence of gut nnd other Tiscera in tl c pleiiml ca\itj {fig In t c
gTos.s cases the condition maj 1>e as.soa*ilcd with non rotation of the gut
(2) IlFnMA Tnroioii Tirr Domk. — This occurs ttsinllv" on the left
the heer cfTcctivcI^ pr ilccts the right dome The endcnce in fas our of wnic
of ll c^ cn*cs lieing congenital is tint sercral cn*cs Ince been rcconIc< m
new Ixini infants The gap in ll e dome vanes m size but is fairh constant m
THU DUPHRAG3I
1S3
position , m the 3eft trefoil of the central temlon, iinmedmteli behind the
entr^ of the phrenic nen e into the iltaphragm It is exphc'ihle on the assump
tion that the pleuro peritoneal membrane faiK to unite completely Mith the
Rcptum trans\ crsum ft la a rare form of licrma The stomach and a portion
(i) Itpmin of (ho fundiH (A) KoniM of (he uppor hairof tho Ntomuch
(r) lli?rnia «)f the jiivts nwHl » (<0 Homia of ll*o wholo Rtomocli
of the ooloii are iinanablv herniated, and, %«hen the gap is large, the spleen
and portions of the small intestine nho Tig 139 represents an unusual tj }>e,
henuation of the stomach through the right dome
(3) pAn\ (TsoiitAOi vr. Hernia — HIiilo herniation through the pleiiro-
2 'entoneal hiatus is the commonest ty^H. of tliaphmgmatic hernia found in
the fatus these are usualU mcomjmtiblc «ith life, and in adults the para-
ccsophagenl tj {w is much the commoiicsl
ALniEVTARY TRACT
Tt\o types occur n true hemtalion through tic
(esophageal orifice, which maj or maj not ho a«i o
cmtetl with incomplete dei'elopment of the crura
(Fig 140) atida partnlt/ioracic 5/0J7iac7t (Fig 141)
In the former type the gastnc fundus is di«i)laco(!
upwards into the posterior mednstinum the cc o
phagus being of normal length and folded eoraewint
on itself In most cases the fundus is to the left of
the orsophftgus encroaching on thelcftpleuralca%atj
In one of the WTiter s cases tlie herniation tooh ji! icc
to the right side of the gullet
The partial thoracic stomach results from failure
of that \Tscns to descend from the primitive thoracic
co-lom mill the descent of the septum tiansversum
The forming diaphragm then traps n varying
portion of the stomach above it The amount
vanes from almost the whole of the stomach to a
small portion of the fundus The oesophagus is short to a degree correspond
iiig to the position of the stomach The latter is somewhat constricted at the
(esophageal ojiening the opening heuig larger than the normal hut smaller
than the full lumen of the stomach Tlie distinguishing feature between this
tjpc and the true para
cpsoplmgcal licnua is tlie
short ccsophagus
( 4 ) Hi RMA TJIBOt on
TIIF FoiUVtFS OF SfOROArvI
— These arc ver> rare The
sac lies behind the sternum
and inav contain colon or
small mtestiiie Postero
anterior anil lateral views
nrcnccesavr^ to demonstrate
them(lig 142)
C)) Acqi irfd Non
T iui VIATIC Hfuma — ^I hesc
arc rare and ma^ occur
m nnj part of the dia
pliragm except the ccntrul
part of the toiulon Tlicir
appearance depends on the
precise Mtc and degree
The commonest site is
through the left dome of
>ir of th<? (iIomAcli lhrou),h tb<? foramen
of Morgttfjni (lateral > icw)
1 Rtonulch i dlooi hnf^4 3 I)ia{ hrit?m
184
thoracic utonuuh
THE DIAPHRAG1I
185
tho (Inpliragm Thej arc reganlctl as non
congenital m that tliej herniate through a part
of the diaplirogni winch is not the site of a
pos'iiblc doaclopmcntal fault or weakness
(0) Trausutic Hlumi. , le licmns follow mg
on woiinch of the thaphirigin, i\cre common diinng
and after the Great War Like the acquired
non traumatic \anctj, they were commoner
through the left dome of the diaphragm on
account of the protective mass of the liver on the
right
Complete Tnoiuctc Stomach — Xumcrou!> 143— ConpemtuicompMe
r ^1 1 tborncic stomach
ca«03 01 this are now on record
R E lioherh has described a cn-^e in a female
of 3 jean and 10 months Tlic cosophagu-> was short and the stomach
bilocular Fig 143 shows the disposition in his case Three similar cases
had been prevTousl^ reported bj Baihtj and Lei] aid, and a subsequent one
bj DunhtU A feature in these cases, as m one of tho writer's (Fig 144),
is that tho viscus is upside down The greater curac is uppermost and
tho canba and pjlonc region form
tho lowest points
The liver and spleen maj bo
involved m a licrma , these are
desenbed m tho section on the
lungs
Radiological Features
TFcn\ifiUF — ■^^am thaphnig-
matic hemi'O are visible on plain
Jiuoro-fcopyc ir-specfiou of the dia-
phnigm Tho erect position is the
most satisfactory for this purjw'.e
Aliovo the diaphragmatic line will
be teen a projection, the hernial
sac, m w Inch, if it contains stomach
or colon wnll he seen one or more
air bubbles and possibly fluid lev els
below the gas If such a hernial
protrusion is visible in a postero
antenor view, rotation of the pati
ent viill show whether the hernia-
tion is at the lumbo costal angle
through the dome, or anterior ^le
I in i'll — /'omiilefo stomiirb
TIk? orpan « up'ide down tlio crralcr eurvolwnnu
upj cmwwt
ISC
ALIMENTARY TRACT
para (Tsophageil licniia> maj easily be o\erlool ed m a postero anterior
\ieu ns the\ are tlien apt to be masked b} the cardiac shadow If
tlicir presence is not suspected clinically, the only clue to their exiofem-e meiich
a may be a faint gas bubble sliadoM ts ith or without a fluid level
An opaque meal €:3:(itn\naUon should be used in all eases of diapliragmatic
hernia os a great deal of information is obtainable by such a method T1 e
examination should be continued untd the splenic flexure is visualised in ca«o
that structure is herniated It may lie necessary to employ a barium enema
for this purpose
Radiograjihically the diaphragmatic hernia; fall into tuo groups those
wliicli henuate into the pleural cavity and encroach cliiellt on the lung «pacc
and those — the para ccsophagealgrouji — which encroach largely on the posterior
mediastinal sjnee Tlie demonstration of the first is fairly simple 'vith a
barium meal examination m the elucMbition of the latter it mn\ tax ones
ingenuity considerabh to obtain sep irate shadows of the stomach, tesophagus
and other herniated structures
Is Hmsiz OF THE Stomach nmotoii the Dour ash Li sibo costal
Asole the (Esophagus w seen to l>e displaced at its lower end towards the
hernia Thestomncli ifhcmiatiHl should be examined wath the patient erect
prone and supine In the erect posture the lower polo of the stomach shows
a chanicteristic appearance As the fundus is raised the dmg on the lower
half of the stomncli undoes the pylonc curio or hook to some extent so that
the mcisura tends to disappear the pylonc canal to point to tlio right and
fhglith downwards and the duodena! bulb to 1 e on a lower level than the pars
palonca lliis appearance is ••ocn in any considemblo hennation of the
fttomach of this tape or the para ccsopbageal
In the prone or supine position — usually the latte r — the upper half of the
stoinach fills and tlie jireiise position ofthe fundus filled with barium iseosili
detcnnined The ii^ual bilociilation of the stomach («u.sed by the hernial
orifice IS also i isible In the region of the hcmial orifice the gastnc mg'® can lie
followe'd from upper to lower loculus A later stage in the examination will
show whether an\ of the small intestine or colon is in the sac The presence
of the spleen in the hernia is indicated if there is a considerable uniform
ojiacity to lie seen m tlic sac Rotation of the patient dunng scrccnm,.
and radiograms taken in two planes sene to detennme the precise Rite
the liemiation
In some cnvcs if the hernia is umall and not incarcerated it may lie n-sit>>e
onh with tlie patient King down or iti the Trendelenburg position
The thief problem in the differential diagnosis of tins group is m distin
guidimg it from eventratjon of the diaphragm (7 i )
liii Papa (rsorUAOi-AL Groii may not be seen on plain radioscopic
inspection of the thorax but as tliev tend to gne u«opliHgcal and/or gastnc
syanptonis they are commonly examined with a barium meal A* tic
THE DIAPHRAGM
1S7
op \que crc im is tracetl (low ii tho oesophagus the gastric fundus can usually bo
made out nbo\ e the diaphragm and close to the ce ophageal bhadow
Having established tho presence of a lesion belonging to this group, it
becomes of 6n»t importance to detcnnme whether it is a true herniation or a
partial thoracic stomach The former is amenable to surgical treatment the
latter is not They can best be dinerentiatcd bv the use of the ‘ double
swallow method in the Trendelenburg position as follows
The patient 13 first given enough of the opaque cream to fill the stomach
reasonablj full and then is placed m the Trendelenhurg po-^ition on the \ ray
table this procedure the herniated fundus filled w ith the contrast medium,
13 visible The patient is then given
a large moutiiful of the cream from
afeedmgeup nndtheprogressofthe
banum watched under the screen
from the moment it issw allow cd until
It reaches the cardm Still in the
rrendclcnhutg position the patient
should bo rotated right and left
until a clear vaew of resophagus
taidia and gastric fundus is ob
tamed AMien this anew ls obtained
it can then bo seen whether the
asophngus is of normal length or
congonitallj short One of normal
length takes a looped course ns it
approaches the canlia indicating
that a true liemiation has occurred
(Fig 145) If on the other hand
tho ojsophagus runs straight down
to the cardia the cr-e is one of
thoracic btomach {Fig I4C) Toob
tarn a film showing this appearance
with (e«ojihngus cardia and fundus
filled the time taken In an opaque
bolus to pas.s down to the esrdia Fw it ^ — 1 «ra lema of the
should l>e mea.surcd fluoroseopicall^ •‘tomach showms tli© angulation of tho
Usually it lakestirototbiwwronds
An exposure is then made the appropriato numlxir of seconds after the jmtient
swallows tho lioUis
In gro-is herniation of the stom ich m winch most of the \ iscus or all of it is
in the thorax there is a teiidcncv al o to imervtou (Fig 147} Tlie greater
cur^c swangs upwanls and forms the hichest portion of the herniation Tlte
pslorus and cardm ma\ lie located fairU cIomj together at the hernial
ALIMENTARY TRACT
THE DIAPHRAGM ISO
Pio 14^ — ConernctAi pArcial thoracic Atomach trith (>hort
<i>v)phttgti«
> u 140 — raw o^wjiliagcal hcmia of the
stoiKHch.tljo fun' J(ii( «.^»jn;r jf;foihorJt,hia» Jo
of IliP tliowT Thi-* Mitt {n_hl antetior
obhiiiio) rhovn the abrof ! anrnhilJO»i of Ibo
»r»oi hnctnwlwrc {t rrnc-JiM tJu ffA«tnc fun iiia
hiatus if the latter is email
It is sui^call^ of great im-
portance in thchc eases to
demonstrate the size of the
hiatU", fiince those mth a
very mde opening may be
difficult to repair The
hiatus is rendered visible
uhen the tuo “limbs” of
the hemnted viscus, afferent
and efferent, are filled, and
the technique of c’samina-
tion should be directed inter
nlia to tlus point
DunfuU points out that
m many cases of partial
congenital thoracic stomach
uith short (esophagus the
eonha is at the top of an ill
developed fundus (Fig 148)
When examined erect, the narrosviog
of the binum shadow may simulate
a carcinoma of the stomach In the
Trendelenburg jiosition the fundus
becomes distended mth banum, and
the gastric nigtc at the diaphrag-
matii; hiatus can be made out Thc«o
two points, in addition to the short
straight resophagus, indicate the true
nature of the condition This
nutliont^ ab.o draws attention to a
wunnion and characteristic apjicar-
a«(t? m the jn true pars
arsophngcnl herniation The ojso-
phagtis niiis straight dowm to a point
ju>.t abort of the Iicmmfed fundus, and
then makes an nbnipt angulation.
U'lUallj backwards and to the right,
to sweep round the fundus jii a looji
(Fig J4n)
AcQriREn IND TnAUM4TI0
Hernti: — Acquired non traumatic
henwe arc cominone«t in the loft
190
ALIMENTARY TRACT
dome and tmiimatic liernitJ occur at the side of tlie ound of the dmpliragra
Radiograj)liic'ilI> thc\ fall into one of the groups nho%e described — Uiiiallj
the former Thc\ should be ndiologicnllj examined m the manner already
dcscnbed
EVENTRATION OF THE DIAPHRAGM
{Syii Petits eventration Relaxatio or eventratio diaphragmatica. Unilateral
congenital elevation of the diaphragm)
In tins condition the affected dome is m the form of a thm fibrous sheet,
ballooned ufi into the thorax In the vast majority of cases it occurs on the
tiu 1 ^ 0 — (ci) eventration with
marke 1 <1 l j Ineenient of 1 part ai I mpd aa
tinuin to tl t ns) I Tliei'ton leli h&h rotate I
with tlic }.mitcr cirve ijfpnnost
Uft suit At tlic time of mating only nineteen coses of right sided eventration
have been reconfed
The abnormahtv wo-s first dcscnlied by Petit (1074-1750) a French
surgeon He recorded tuo cases one of which apjicnrs to have licen a true
eventration and the other a diaphragmatic hernia Moodbitrn Morison gave
a full nccoiint of tlic condition m 1^22
Tnouicn — Ihis is still obscure Paralysis of the phrenic nerve vrhen
devilopetl gives an appearance exactlv smiihr to the idiopathic or congenita
cv entratuin and it is tempting to ascnlie all cases of ev cntratioii to that caiM
This could not account for the large prepotideratue of cases of eventrationvvliic i
(f.) n e is» nt cnp«> mp nr
Tl p gfutlrip rotation hns re luced itsplf
THL D1\1*HR\0M
191
occur oti the left side rs phrenic nenc panil 5 ’bis occurs on either side imparti
Again in certain ca^es of congenital e\entntion wliicli have gone to
aiitopaj the phrenic nerve shoMwl no abnormality
On the evidence n\ ailablo so far it appears probable that there arc o t vpes
(1) Congenital occurring on the left side almost exclusively
(2) SecoiKlnry to plirenic nerve paralysis anil occurring equally on
cither side
Ihe only features tint help m distinguislung betueen them are the side on
uhich the lesion occurs and any history of damage to the phrenic ner%e
PATiroLOO\ — Ihe affected dome is com{)osed of a thin fibrous sheet dis
phetd tuo to three interspaces upu-anls m the thorax Very commonly it is
situated on a le\el with the fourth interspace anteriorly As a rule there is
no trace of muscular tissue m the fibrous dome
Radiological Features
^\oodbum Mon on grouped the radiological features under tjjo follomng
headings
(1) liiE DrAiunAosiATTO OuTLiM — This IS high— pevcnl mtcrspaecs
higher than the normal — and forms a regular bou line or arc right aero s
the lieniithorav This arc is maintained by the ballooneil gcMtno fundus If
tlio splenic flexure IS gas distended also and in the dome there may lie a slight
notch m this arc at tlie point of apposition of the two structures Diaphrag
matic hernia usually presents a difTcrcnt appearance The hermal sac pro
duces a hump in the <liaplinigmntic outline and some portion of the diaphragm
IS usually y^s^bIe If the hcrnin is very large resulting from almost complete
ah*^ncc of the left dome it may be impossible to distinguish it fron^an cy entn
turn Such hernia! defects are os a rule incompatihlc y\ith life
In right sicleil cyenfration the dome is not so high and shoiys no gx*? he!o\y
It In phee of the diJatc<l fundus tending to lift the dome there is the main
innsa of the liyer restraining the upyv~ml thrust of the abdominal musculature
(2) Tit r Contents of the Dome — On the left the greatly distended gastric
fundus occupies the greater part of the dome The splenic flexure also lias its
plico therein and nt a loivcr leycl the spleen On the right side the dome is
occupied by the Iner
(3) I y NO Tissti yTsruLE tiirovcii tiif Dome — This yyill l>o seen if the
gaseous distension is considerable and the lung tissue at the base of the lung
postonorly normally expanded
(4) Moy EiiFNTJj OF THE Dome — TJicse are of prime diagnostic importance
and should lie noted most carefully Moycinents arc cither absent or more
comnumly inrodoxicil i e an nptvnrd excursion takes place dunng mspim
turn nnti mcc ycrs<\ Tlie«c p.iridoxical moyements are never markcil
Tiny arc kno«n on the'CerTtincnt as Kienlaick s sign and are said to occur
occasionally m large hcnii'e
192
ALIMENTARY TRACT
(5) Tut Ga'^thic Contexts — A fluid level w commonlv a i«ible, imle» the
stomach is einptj Tins Ie\cl Hstatedalnajs to be at that of the canha Tim
IS explicable on consideration of the mechanum of eructation of gas Tins takes
place u-suallj nhen the individual is in the erect position Gas vriU be expelled
from the stomach during eructation up to the point where the fluid gastric
contents nse and seal off the canlia At tluit point escape of gas from the
distended fundus into the gullet is stopped nnd consequently the fluid level is
prevented from nsmg above the cardia
If the fluid level is of fair extent palpation of the abdomen cames ripples
m It Tlicse are clearly seen on screen examiuatton
(C) CvnniAC Dr‘'PLACFMEVP — The heart usually shows some slight ilis
placement to the right and aUo sbght abnormal respiratory excursion moving
to the right on inspiration
(7) Gasthic DEtORvrtTX — ^Tliis is present fairly constantly, and is of the
nature of a hiloculation According to Momon it is cxiiecd by an upwanl
displacement of the greater curve into the dome, and a rotation of the stomach
on Us fixed points cardi-v and py lorus This torsion may amount almost to a
volvulus and produces the bilocular appearance
Of the above signs the contour of the dome Us position nnd Us movements
are constant and cartlinal the others are not always present
Differential Diagnosis — •Temporary elevation may occur from marked
gaseous distension of the stomach The elevation la not usually so markeil
and the diaphragmatic movements ate noimal In hernia through the dome
the contour of the dome is less regular In one view at least, the postero
antenor oblique or lateral the normal portion of the dome will be visible
(with the exception <if the rare cases of complete absence) The movements of
the Kic are variable Tlicre may be none or they may be reversed, or they
may follow the movements of the remainder of the diaphragm Tlio clue Lcs
m the latter If any of it is visible fliioroscopioally , Us respiratory movements
are seen to lie normal
J Qufmi has suggested two measures which might lie of use ui the
differential diagnosis Ixitwccn eventration nnd a large hernia through the
left dome (1 ) Pneumo pontoiieuin mav enable the diaphragmatic and gostne
fundal shadows, to lie seen diss^aatcd This is hardly practical politics
12) Fnradic stimulation of the phreme nerve may produce visiWe moxcmwit w
the mnains of the diaphragm m a large henna when none can lie made out on
onhnarv forcxHl respiration
PARALYSIS OF THE PHRENIC NERVE
Hus mav result from mnnv cau«cs such as w ounds in the neck, or pres.‘'nrc
in the neck or tlie thorax — e>pecially from mediastinal tumours It h
commonly induced thcmpeuticallv m ta-'Os of hronchicctaAis and pulmonary
tulierciilosi-S, and the sequence of events following phrenic avniLion no'V
THE DIAPHRAGM
105
•well known For n few (la\s after section of the ner\e slight normal move
mcnts take place in the paralysed dome Then o\er a pcnod of two weeks
the alTected dome gradually ascends m the thorax and either becomes immobile
on respiration or presents reierscil nio\ements iisiiallv slight in range During
this period atrophj of the muscle takes place On the left side thinning and
stretching of the degenerated muscle continue until in some cases the
t^plcal picture of left sided e\cntration is reached
SUBPHRENIC ABSCESS
Siibphrenie abscess arising as a complication of perforated peptic ulcer
gall bladder disease or appendicitis mnj occur on either side On tlio right
wde the nbst'css forms
lietw een the In or below and
the diaphragm nbo\e On
the left side the lower
boundnrj is formed In
etomnch and spleen
X»ray Features — In a
t\pical case the dome is
rather high— a centimetre
or two raised— and nnj be
fi\cd on respiration The
diaphragm is rendered
immoliilc bj a protcctne
reflex similar to tlint which
places the abdominal mus
culaturo on guanl in pento
nitis \n> deforraitj of
the contour is unusual In
n jK^roentago of case. ga» »"■
IS present in the abscess
ca\it\ (big 151) Tins arises either from the passage of air from the stomach
through a perforation or from the direct action of gas forming organisms such
ns B irdrhw
On ihe nght side of t7ic oMoinen this gas is obvious if the patient l>e examined
erect and although these palientsorcasa rule lerj ill a rediogram can usually
bo obtained with the patient sitting up in bed In mich a posture tlio gas is
clearh seen m a Hicr between dwpbmjpn and h\er if the amount of gas
present Iw considerable a fluid Icxel in the ab’^ccss caMtx will bo apparent
Two other conditions can give a somcwliat similar nppeamnet. of gis in this
region On rare occasions a loop of transxersc colon wanders up between the
Jiver and diaphrigni and ma^ contain gas Again m a pani cesophagael
V n n — 13
104
ALntLNTAR^ TRACI
hernia t!ie herniated gastne fundus may lie to the right of the {esophagi
The chnieil features are enough to exclude the«e tuo
On the left side the dome is raised and immobile but if gas be present it ni;
be difficult or impossible to differentiate it from gas m tlie stomach or colon
Changes tn the /«ise of the lung overljing the abscess are commonl;y four
A small pleural effusion enough to fill up the costo phrenic angle is frequent
present In the lung itself n inrjingdegn^ of stciated opacitj disposed in
horizontal layer across the base and a little above the diaphragm is a usu
appearance in thei>e cases This represents a congestiv e reaction with eor
degree of collapse from the upwawl displaced diaphragm If the opacitj
the base of the lung be considerable it mav be difficult to decide wheth
a pneumonic consolidation and not n subpliremc abscess is the cnu«e '
the trouble
SUBHEPATIC ABSCESS PERIRENAL ABSCESS
In this condition the dome is raised a little and fixed no pulmonai
changes are present as a rule It is desenbed in the section on tl
uninn ejstem
TUMOURS AND ENLARGEMENTS OF THE LIVER
The exact amount of elcialion of the dome anil the degree of dhtortic
thereof mil depend on the nature of the hepatic enlargement Iljdatid cjs
and tumours if sUintod near the upper surface of the liver may produce
mild rounded bulge tn the diaphragmatic contour but usualh no buc
deformity is produced
Hepatic enkrgemontb from gener il dt eases sucli as cirrhosis or oonoestioi
produce no distortion of the outline Incvamming thebe hepatic nbnormalitu
rndiographicallj it is important to take note of the position of the loner edg
mIucIi is usually visible in a plain radiogram of tiie upper abdomen
CROSS ENLARGEMENT OF THE SPLEEN
Tins mav raise the left dome to some extent Tlie clinical ev idence is decisti (
FREE CAS IN THE PERITONEAL CAVITY
As this IS usuallv dcnionstroteil radiogrophicall^ m relation to the dii
phragni it maj be considered here It niaj result from
A LvPAroTOMv — ^This is the commonest cause and on l>cmg pre«cnte
viith a radiogram shaviing gas in the jieritoiieal cavity this point bhould fir*
be determined Air is sluiil> nbsorI»cd and traces mav lie found iii «■
nlKlomcn a neck after ojicmtion
R PniioRATioxs OF Till AinirxTAnv Cvsai
C Gas niiJMixo Ansrissis eg bubphrenic
THK DIAPHRAG'M
195
D Accidfntai. rmiORATioss of the abdominal ca%nty during artificial
pneumothorax, etc
E Arn Insufflation of the PAUxiPrAX Titbes, if successful
Radiological Demonstrabon. — ^The best site to demonstrate free air is under
the right dome of the diaphragm Tins normall> contains no gut ; the li\er
keeps the latter ^\ell rcmo\ ed Tlie examination, screening and radiographic,
should be m the erect or sitting |K>sture , iisualU the latter is all that is possible,
hut it suffices If only the recumbent posture is permissible, the patient
should bo placed on his left side, the tube centred honzontally jn front of him,
and the film behind The radiogram wnll shou air hetneen the lateral abdo-
minal ^\all and the liver If, m the sitting position, a crescent of gas is seen
between the h'cr and diaphragm, it is almost certamlj due to free air One
fallacy already mentioned must be taken into account, that of hepnto dm
phragmntic inten’os>>tion of the colon On the left side the gas bubbles in
the stomach and splenic flexure complicate the apjicarance, but tf much fit® gas
bo present, it can be recogmseil also on tlm side
REPFtlFNrES ,
AhaM'. a W , Uni J . 1915. 1. 248
AKEniLvri, A . Arfa u<t<hal , 1923. II, 14
Aim FCIlT, II U , Ttfrliflir (jfb r«>nfj#n*tr , 1929, XXXIX, 231
Harclay, a F , ‘ TIic Dijp^noTrict.’ Ivondon. 1935
llLinivO it , Arid I'alh Mtenbtal , 1913, Supp \VI 18-30
llruc, A, “ Rflntgoruintcrsuclnmgcn nm innenrehef ties Veri1aminio>l.snaIf, ' 1030,
JM J Udfhol. 1925. XXX. 372 JM. 1011. XIII. 87
Capmin, R T) , ‘ Roentficndi'ijaMi'i^of ttl^casesof the nlinirnt irv cainl,” riiilai1clt>liia,
1920
UumR. H li, Uni J Sum, 1927, \\, 316
('A’l.J T.J Amfr Vet! A** , 1920. LXXV. 1463
( UAoi I , il , * Kliniwclip Rontcendiaguoatil. dcR Vi rdanuiigskunlf*,’ Berlin, 1928
111 SAL 1’ . and BrcLtri. 11 , /V lf<*I,|932 XL, 991
Dimujt.T r,Jfnl J .Sury. 1931. XXII, 471
I u*TFnM \x. Goo n.J Atner V«I .I»« , 1031, XC\ I, 173
FoK«’'fLL. G , Atner J UoenIgenoJ . 1923, X, 87 , ^l<At TioAicf , 1024, III, 217-18
rRsrsKtr. A, ForUehr geb 1927, XXXVI, 687, Uni J J'tnliol , 1927,
XXXir, 401
G\Gi II CoLltTSTT, I’roc U kor Vnt . 1937, XXX, 1371
Hlsie. J B.Bnl J Sury . 1032. XIX 52T
Jlmt'T.A V^Quiiri J 3/rd . 1911, MIL 300
lluiU'T A F , and Hnir.fi-. F J . Ouy • Iloip Ftp . 1024. LXXIV, 432
III R-’T. A F , and V J . Gastric ami Dundenal Ulcer, ’ I ondnit, 1029
K \iiUNKA, N , Aela Liuliol , 1933 \\ I, 111
KlLLorn 1 L Tile Dnodenum. ' Xi» lorl, 1033
KlPLEY.r, Riiciit Advancesm Badiolrtjrv’ lAtiidon 1936
Kiuklis.B R. Imcr J rtintlgenol . Wl XXIX 4. Ihd . 1914. XXXl, 181
Kniv-.I .nndBtrh.W (..Ann ^nry. 1911, X( 1\, 311
L^Ni.N Metl J 1937,11,49
I moLx I yuAJil*. R , and Lajicia C«.i>fri>n, J , lirA Mai aj>f»ireil tligeeli/, 1973,
\.\in. 113
LiUalh.L 3,J Inirr Vet! In* . 1911. X< 1 1 179
I.n.<MAiri , 11 , I rr/i Jlfrf, Gm . I*il4, W II, 4tl
inc
altme:^ary tract
MACCvniT. W C,J Amer.SM vt*» , I92-I, LXXXIII, 189^
Siru^T'SEN, T , nud Sloop, J I* , Jffa Padiatr , !932, XIV, 19
Millfp, R , nnd CouirrxLT Oagf, 11 , ArcA Du ChIMh , ID10, V, 8*1
iloPLLT, J . nnd Eocert«, W. M , Dnl J Burg , 192Jt-0, 16. LXII, 239,
OnoEiusP N Ji.nril J Sury. 1029-30, XVII, 692.
Odqti-t, il , .Irfa Bn, hoi . 1937, XVIII, 112
rATTi''ON, A C , Arch Surg , 1934, XXIX, 907
Pall. L W , Jmer J Boentgenol , 1934, XXXII, 43
Pin ittc). (' , Badiol 3[ed , 1934, XXT. 793
RAVurs. 1 S, PE^PER^.EA«», E P, Johnston, C G, and IIode?, P, .tw<T J
liociihjMtol , 1030. XXXV, 306
RonutTS R E , Bnt J Bndiol , 1927, XXXII, 17
S vsm lu, R , ForUfhr gtb Honlgenttr , 1932, XLVI, 676
SciUNZ, HR, Bafn'cii W ,nnd FniErn., E , “l,el«rlmclider KontpcndngnOAtiU,” lA'ipzic,
1032
fcPiTZLSBfKCLft, () , 1934. VI, 667
SriUfiO-'. 1. I . Qu,iri J , 1 / 0 / , 192> C. XIX, 1.
nioM-ON. A , lln( J/o/ J , iniO. II, 949
'Dmnino, L J /Wwf , 1933, VI, 644
V ALTON, A J , * A Toxtliook of the iMirffjcal London, 1030
VlLKU.I) P j 19il, VIII. 204
Wiu. 1 , 11 , for/wAr grb Ilonlgtintr , 1933, XLVII, 188
WonPHLRN > 10 RI' 0 \, J M, .IrcA J.’adiol VIefIr, 1923, XXVII, 333 5 Jf-id, 1023,
XXVIII, 72
PART ONE
SECTION III
SMMjL I^T1:STINK, appendix and LVKGE INTIi:STIiVE
CHAPTER XV
THE SM\LL INTESTINE TECHNIQUE, ANATOMY; VND PHYSIOLOGY
roR TiiL purpose of tins ticcfion the small nitestine maj be regarded as that
iwrtion of the alimentarj canal between the duodeno jejunal flexure and tlie
jJco-ca?cal junchon -
TECHNIQUE OF INVESTIGATION
fho small intestine la in\cstigntcd by the opaque meal AUliough
tlic baniini enema occasionally Icabs past the ilco ccecal spluncter into the
terminal ilcuni this is an undesirable accident m that examination nther thin
n practical means of tni*cstEgating the ileum Wiidc the binum meal forms
the principal inetliod of mvcstigationr at times some information max bo
gime<l by a phm radiogram particularU in email intestine obstruction Air
then fonns the contrast medium
Fluoroscopy and radiography arc lioth of imi>ortante in the mvestigitiou
of the small intestine Fluoroscopy is of value m the study of its function
By it peristalsis can be obsened, and nl-jo the passage of the opaque meal along
the jejunum and ilcmn This is licst conducted m the supme position For
the demonstntion of fluid Je\eU, the erect posture is nccesbiry
Radiographs giscs the opportunity to study the morjihology of the gut in
detail and a senes of radiograms taken at fifteen minutes thirty minutes, one
hour, three hours and six hours after the ingestion of an opaque cream will as
a rule show the s anous portions senatim
ANATOJIV OF THE SJIALL INTESTINE
The small intestine is arbitrarily divided into an upper jKirtion, the jtjnnum
aliout 8 feet in length, and a lower the ttettm about If? feet in length The
jejunum occupies the upper left part of the abdomen, lielow the tnimcrsc
colon ami stomach The ilcum lies in the lower right region Very frequently
the lower part of the ileum lies in the pelvis the terminal jiortion being directed
tipwnnls to join the c-veum
js-
19S
ALRIEXTARY TRACT
Iherp js no abrupt change from jejunum to ileum The transition 13 a
^ erj gradual one Ne^ erthelcaa, if a portion of the upper ]ejunum be con
traslcd Mith the lower ileum, marked differences are endent anatonmallj
(and conseqiientlj radiograplncallj ) The jejunum is larger in calibre, and it<
muious membrane bears manj plicae circtilares closely approximated to each
other The Pejers pateheis are few «»mall and far between The ileum is
narrower has nianj Pejer’s pitches and graduallj lo‘:cs its phcai altogether
as the lower end is reached
The mcseiiterj renders the jejunum and ilcum freelj mobile, but m spite of
this they tend to keep their relitiie positions m the abdomen fairly consfantlj
MOVEMENTS OF THE SMALL INTESTINE
The classic experiments of Cannon on amisthetHed animals with the pen
tone'll canty opened and the gut e\i>o>ed and radiogruphicallj in tlie intncl
animal showed three Upes of movement rhjthmic segmentation, true
{icristaltic waves and pendulum movements
The segmentation 13 fiupjiosed to occur first, after the gut Ins been filleil
A senes of annular contractions occurs dividing the contents* into discrete
masses In seven to ten seconds a second senes apjiears, splitting these
boluses the halves joining with their neighliours The function of this is
supposed to ho thorough ndiuixtiire of the food with the intestinal jmres
hen this lias proceeded for upwards of Iwlf an hour pcnstalsH is then wid
to occur driving the food slovvlv down the «»mnll intestine, at the rate of nn
inch or two per minute
Radiological Features — Rodioscopic investigation in tiie human subject
after a barium meal ahovrs a rerj different picture The movements are seen
fo van to a great extent in the jejunum and ileum
Tiir JcjrscM shows a state of restless aetivitj rciuUilum movements
arc nov or seen As soon as the first bolus of the ojKique ore ini passscs round
the diioflenum and <n cr the duoficno jejunal flexure it is svrept rapidlj through
the first few coils of tlic jojuinini and at the same time assumes a finely
fragmented state As succeeding portions of the meal are dchvered hj the
duodenum f ho>e that hare gone before are driven hj peristaltic wares farfhir
down the jejunum until most of that portion of the intestine is flomlevl with
banum cream m a fine state of subdiv iMon (Fig 152 ) Tlie onwanl progress of
the meal is the result of peristalsis but of n much more rapid and vigorous
nature tlian was descnbetl bj the expcnmental workers
The fine fragmentation of the contrast medium is at first sight perhaps
purzhiig but Iiecomcs clear on a consideration oflivinganatoniv of the jejununi
If a large Imlus lie ob‘*erved enteniig the jejunum, the gut is monientanlv
distended and a homogeneous shadow appears shaqilv indented hj the phcie
circiilares 'fins distension however at once stimulates a jfemtnitic wave
and on the passage of tliLs wave the gut resumes its normal degree of patenoj,
THL SAIALI. INTESTINE
100
naniel> a state suflicieutlj collapsed to thrcm the plica? anti mucos'i into a fine
rugoHitj tho interstices of whieli are filled with a thinl> spread layer of
intestinal contents The miiscolans mncoa<e pla\s an active part in this
“ plastering of tho mucosa and the tadiographic effect is to produce a
uniform mucosal
of tins 13 obvious — [ ^ ^
to obtain intimato
mixture of the food F ^
and intestinal score ^ P t
tions and the sub ‘ ;
sequent absorption i ^
of the food when >
digested The rapid iar- ^ .
jienstaltic transit
of the meal down
the jejunum libewiso
aicU both processes
b\ bringing into use
as largo n aurfaw of
jojuiud mucosa as '
possible
In mdi\idiin!s in
V horn gastric eiacu ,
ation is sen rapid
the jejunum has to '
accomiHodatc such a
large quantitj of tho
contrast medium
tlmt fragmentation
IS unable to take [
place at first and a *
considerable length Pmiwvicw oftlBnormalduolenum jejunuio and i{(mni
of the JOJUnilin tna> t *o l o its after an opnrjuc menl
phow a more or
« oftlBnormalduolenum jejunum and i{(mni
o I o ITS after an opariuc menl
less homogeneous shadow but this oxcrloading is prohahlj much rarer m
onlinarj circumstances since a plain banuin cream passes out of the stomach
much more qiuckli than ordinan food After gastro jejimostomi and partial
gaslrcctomi it noniialh occiiis to n marked dtgree
Tiir lui M — As the opaque medium reaches the ileum a gnidual change
in the \ ra\ api>carance takes place The peristaltic actii it> is slowed down,
and tho rate of transit dimmtslied As the mgositv of this portion of the
200
ALIMENTARY TRACT
small intestine is much less and the pbcae prOj^ressivel^ fewer in number
fragmentation < f the ileal contents does not take plate It is here however
that segmentation actmtj can be made out to some degree and this is the
more clearly seen the nearer the ileo-carcal junction is approached T1 esc two
movements — peristalsis ami segmentation — are difficult to make out fluoro
scopicallj because of the close apposition of the ileal coils Tlie terminal
ileum often King separate from the remainder of the ileal coiL is the lea t
nctne part of the small intestine It is a more or less straiglit seg
ment runnmgupwardsandoutwards from the pelvis to theileo c«ecal junction
By careful ob^erv ation under the screen slow segmentation can be made out
in this portion and at infrequent intervals a penstaltic wave ejecting a lwlu«
of clnme into the cecum
^lorphologicallv the TFRjrrsAL ilecm shows man\ minor vanations m
disposition and contour Care should therefore be eTerci«ed in pronouncing
am giien api>earance as pathological Its mobiJit> in itself and its mobihtj
relitn eh to the c-ecum and appendix should be carefully noted Itsnlwilute
mobilitv de|iends on the length of its niescntcrv and u.uallj decreases m
degree as the ileo-c-ecal junction is approached It should be home in mind
that the mo^enterj maj virtually disappear m the last few inches of the ileum
m which case that portion will Ixs relatively immobile Tlie terminal ileum
should also be mobile rehtivcly to the CTCuin and appendix Fixation to
cither of those shadows is worths of suspicion
T1 0 terminal ileum is best investigateil at the sixth or ‘^eNenth 1 our after
the ingestion of n larium meal and is most accessible to palpation with tie
patient supine Occasionallj even in that posture it and the csecum ore «»
deeplv situated in the pelns os to bejond the effective reacli of tl e mam
pulating hand In such ca*e the cnecuin maj occasioiiall> lie coaxed from the
pelvis b> the Trendelenl urg or knec-cibow position
RATE OF TRANSIT THROUGH THE SMALL INTESTINE
This Is. 80 variable that no exact figures can be laid down Fortunatciv it
IS of little importance except for the question of ileal sta«is
The average time for the hcail of a banum meal to reacIi the ilco-c'cval
junction IS ont and a half to two hours According to Hurst the small intes
tine should be clear four hours after t! e completion of gastric evacuation
This time is often exceedetl and it is not uncommon to find the last few mcl es
of the ilcum filled with banum Niven liount after a meal and more than four
hours after the stomach is emptv Tim amount of the gastnc residue shou! 1
be taken into account ns well as the time factor in the assessment of ileal stasis
Thf Gastto n rsL Rrixrx — ^\Mien food enters the stomach the terminal
coils tend to emptv into the c'cciim This was described b^ //f/r*! under tie
tenn gnstro ileil reflex It is an index of the clo<e as.ociation lietwcen
THE SMALL ECTESTIXE
201
tlicsc tw o portion's of the alimentary canal, and is said to be inhibited m chronic
appendicitis It has its pathological counterpart m the " i!eo gastric ” reflex
of Jiarclay In tins connection Barclay noted gastric stasis in cases of disease
m the region of the temimal ilcum Tlie inference is that a lesion in the right
ihac foasa, such as a chronic appendicitis, if it be causing ilcal stasis, produces
a reflex closure of the pjlorus as soon as the ilcum liecomes filled wth food,
and thus slows down the rate of gastnc e\acuation m its later stages
THE ILEO-CiECAL VALVE
Tins xaUe is rcalh a sphincter, according to Kctlh It is responaire to
penstalsis of the terminal ilcum, w hen it opens, and is said reflexlj to close — or
exhibit achalasia — m respoasc to the stimulus of a chronic appendicular le<»ion
Its competency as a \al\e to the pressure of a barium enema u serj variable
in nt least 50 per cent of cases it is incompetent, and the opaque enema passes
freoJj into the ileum
It has been suggested that this incompetence is patholopcal, although m
what exact waj it is not quite clear Indeed, one surgeon de%nsed an
operation to fashion a new salve to prevent regurgitation an interesting
example of surgical cariicntcring gone mad, to the exclusion of all phjsio
logical considerations
In the wntora opinion competency or otherwise of the i?eo ctecal valve is of
no clinical or diagnostic significance uhatever
CHAPTER XVI
diseases op the small intestine
MECKEL S DIVERTICULUM
This is, nn important structure surgically It is a congemtal abnomiabti
resulting from the persistence of the intra abdominal part of the vitelline duct
It usually springs from the convov or anti mesentcnc border of the ileum
somcuhero within 2 feet of the ileo taecal junction It occurs in 2 per cent
of subjects
Varieties — The normal process of obliteration of the \itclline duct mat be
arrested at any stage Tlie diverticulum may be a blmd-ended patent tube
a fibrosed t-onl connecting ilcum to umbilicus a combination of these two or
it ma\ form a fistulous opening at the umbilicus The complications which
may nri«e from tius abnormality arc several including acute divertinilitis
intussusception volvulus or strangulation of small intestine bv the (liverticu
lum acting as a band Patients are frequently sent to the \ my department
for investigation of a possible MetKcIs diverticulum but it is frequently im
possible to demonstrate the condition radiographically A positive diagnosis
of AfccI el s divcrtitulum can bo made only when the divertiaihimissceii filled
with barium and so disposed as to demonstrate both the hhnd end and the
connection with the ileum
Apart frem thi'? radiology can nfford lielp in two comphcations — chronic
obstruction rcatilting from band like action and fistulous communication of tlic
umbilicus In the former the npproviniatc site of the obstniction can be
demonstrated but not the cause and in the latter injection of the fistula with
a bvmim cream will show its connections clearly
ACQUIRED DIVERTICULA
Acquired diverticula of the small mtcstinc are not uncommon Tliev
consist of protrusions of the mucosa through the miisculari-s at the mesentcnc
liordcr arc usualU multiple and tend to develop particularly m the ilcum
Thev V ary m sire from a pea to a hen a egg
These diverticula have little clinical Bignificance Thev rarelv become
inflamed or give rtso to syniptoma Tlie chief radiological importance
thev have is m differential diagnosis for m the erect jiositions they may give
n-«e to fluid levels in a radiogram
The radiographic features vary according to posture If the patient
recumlient the diverticula appear afterabamimniealhasrcaclicdthosmal m
radiologieMU TJic presence of fluid lc\el3 is an imjxirtnnt radiograplui,
feature of snuiU lnte^tlne obstructions and must lie distinguished from tliose of
di\ crticula Ihc difTcrcntnting feature of the di\ ertieulnr tj*pe is the globular
nature of the combined air and fluid i-hadou and its small sire The main
l>ortion of the bowel is seen to be nonnnl m calibre and mucosal pattern and
the demonstration of the dncrticulnr necks is dcci‘»i\c
FISTUL.E IN CONNECTION WITH THE JEJUNUM AND ILEUM
Tlic radiographic dcmonstmtion of external ristulx! of the small intestme is
as a rule simple
Ml that it IS ncccvar% to do is to mark the ojiening of t'-" «.
wire ring inject a little banum cream through the fbtuli aiu^
204
AUMENT\11V IRACT
butjon in the abdomen -under the fluorescent screen Stereoscopic radiograms
are wmetimes of \aliie in showing the ramifications of the sinus and its wnncc
tion with the bowel {Fig 154)
Internal fistulm are more difficult of clutidatjon unless tl e t-oranmnication
be with a Yiscus other than the Bmall mtestine eg storanch colon or gall
fjo I.>4 — DmiMc pstfmul onj duilIp nUrnal II tula of tbp Kfnall ntt^tiru* follo»i^
npp« I itis. On njoctine an opo<|u erram into the lower « nua (1) the cream out! neJ the
mall u te«t ne esrapwl Iron the uj per » nu« ( J a I fnsll tracVol alon., towards the ca^^to
I ladder If the fistula I e between litgh jejunum and low ileum a barium meal
might give a clue b\ showing the sliort-circuitirij, of a hrge portion of the
intc->tine but a negatne rtsiilt would obiiousK Ixi of little significance m
this connection
OBSTRUCTION OF THE SMALL INTESTINE
Acute Obstruction of the small intestine is « surgical emergenev and
such rarely read es an \ raj department Of recent years however inobila
DISEASrS OF THE SlULL INTESTINE
205
^\a^d X raj apparatus has made it possible to X mj such cases quicUj and
without disturbing them, and information maj be obtained, bj a plain radio
gram taken in this u a^ , as to the «ite of the obstruction Needless to saj , no
contrast medium maj be gi%en, but the gas present in the gut aho\e the
obstruction is often sufficient for this purpose In obstruction of tJie small
intestine the gas filled dilated coils above the block are visible, while the colon
is colhi>*ed Some idea of ii hether
obtained by the number of dis
tended coils
PaUy and Aecroft have drawn
attention to the different pattern
made h\ the various fc.ections of
the intestine in a state of acute
distension This maj be a help in
determining the site of an obslnic
tion since thej maj be visible in
a phin radiogram Fig 153 shows
the 'ippcttrancc in isolated eoiK
The first 10 feet of the jejunum
show s a regular and complete cro®s
hatching, from the shadow of the
stretched pIicT* The ileum shows
no sign of phete The colon pre
scuts an outline retiming some
trace of haustration while the
jilici! are incomplete and tend to
intcrdigitite
In acute obstruction tlie erect
po'turo js rarely possible Occa
sionallj the patient inaj be raiswl
on a tilting table, but to demon
strate a fluid Icecl satisfictonlv
the perpendicular must lie attained
and a more practical methoil of
demonstrating these levels is with
the patient lionzontal and m the ng
block is high or Ion in the gut imj be
Fjo IVS -~P1 au} rod o^ram of <«>tat£sl roib of
intt^tmo dt^ten led with air to show typical iti«
tciuion pattern of d ffcrcntnogmcnts of intestine
jejunum ileum troa^verso colon pcltic colon
from above downward*
It or left lateral position The radiation
IS honzontallj directed, and jiostero antenorU relative to the jiatient, vnth
the film m front
Chronic Obstruction — It is however, m chrome obstruction of the small
intestine that most information can be obtained for in it a barium meal inav
l)c given and the state of affairs more clearlj made out
V note of warning must lie sounded legawhng the ii-«e of the lianum meal
in these ra5cs Oiilv if it is quite certain that the obstruction ts chroznc and
206
ALIAIENTARY TRACT
not ncnte dare one gne a barium meal Further, if the chronic obstruction
turns out to be colonic, disaster maj result In such case, inspissation of the
slo\sl> moving column of bnnum maj convert a chronic obstruction into an
acute one It is therefore safer first to make a barium enema examination to
exclude colonic obstruction Having done so the meal may then lie gwen to
investigate the state of the jejunum and ilcum
RADiooRAnno ArPFAR.vNCES — In the erect pontion horizontal fluid levels
form the most stnking feature of small intestine obstructions (Fig 166) In
plain radiograms this fliud level
IS rendered visible bj the collec
tion of gas above it If a barium
meal has been given, the baniim
filled coils arc also seen The
length of these gas fluid levels is
V arnble and the large size of 'Ome
of them serves to distinguish them
from tlio shadows seen in diver
ticula Occnsionallj gas and liquid
faces in the ascending and tnms
verse jiortioiis of the colon niav
present fluid levels but tlieso are
usually fliTiitcd bj haustral con
traction and fbeir colonic distn
bution is usually clcarh apparent
Jn the supine t>r prone jwnlion
the tlilatcd banum filled coih give
n characteristic appearance (tigs
hi? 1(,0) A ladder pattern
inaj be assumed bv the cod^ and
the mucosal relief pattern of the
cods themselves is verv tjpical
The lumen is vndened and the
barium coated phea* cause a clo'C
cross hatching in the imicossl
velftxf y/vWtTiV TVic yAu-'x.- V/ewig VViX; vWa^TiVavt* hwft tbaic
normal suuions reduplications 1 Ins straightening of the plicf is the deciding
jHimt m the cstiniatum of obstructive jejunal distension
A rough guide as to the site of llit obstniction is given bj the mindwr of
distended cods and the ( vtciit to wliich thov fill the abdominal cavitv Iftbe
olistruetion Ik* colome the i?mall intestine obstruction is ns a rule Ic^s and
^ weous distension of the <s)l(m fills the pictiirt liternll> ami melai»hoTicvUy
Ibe degrw* of j>cn«tnlti netivitv ns Mtn on seretii cxaiiiiintinii vanes
n( cording to the degree and dumtinn of n rhronie ob«fniction If markon
Vie 150 — OlwlTOctum ol tf*nn n»l >1 um from
B Ilu*s ona I ] > II ra I ^ntm in cm*! pox Imn c) w
II g mult I lo fl II 1 IpicIx
>i<j 157 — fromob«Jru«»ne l/an«l (I‘/t»n© i«?u )
coils in winch the splash occurs can be <lc(crniincc{ This, when obtained, is
an important sign, ami one practicallj iKitliognomomc of chronic obstruction
HERNIjE of the small intestine
The presence of a loop of the small intestine in a hernial sac. can as a rule he
dtinonstriled In a barium meal c\nmina(ion Tins is best seen in the inguinal
>arieU when the baniim filJwl loop w obser>cd descending into tjio scrotum
In the femoral tjjie jt is seen m the upper inner part of the thigh, and m the
\cntral hernia a lateral view shows the banuin filled gut m the sac It is
mad\i‘'alilc to omploj this methotl for the demonstration of incarceration
for fear of overloading (he loop with honitni ami so precipitating a sfrangu
Intjon In tnves of strangnlatnm it is olmou-I.v not onh inajiphnWe but
aitunllj dangerous
20S
ALI’MENTAKY TRACT
TUMOURS OF THE SMALL INTESTINE
The pm-ill nitc'^tine is rorclj the site of neoplasms, either borugn or
malignant
Oi- TJir IvNOCENT T^MOEBS thc least uncommon nrc the adenomas either
Fir I 8 UraloWnirtion uiOi Islatton Ironpxww
sohtar\ or multiple Still rarer are fibroma ]i|>oma and m\omo AUtjpes
tend to become pedunculated
in tlieort tlic\ nhoiild uhen the% obtain a moderate size Iw
demonstrable in a bnrmm meal examination in pnictict tlie^ gi'C no cunirtJ
hint of tluir existence until tlie\ cause intussusception or obstruction whm
the radiograplnc picture is that of the complication
CsncrsoMA of the small intestine h osualU situateil in the lower ileum
and tends to form an nnntihr coastnetion leading to obstruction
DISEASES OF THE SMALL INTESTINE
209
has reported a case of non obstructing carcinoma of the jejunum which showed,
with the banum meal, a solid filling of the affected segment, with absence of
any muco-’il pattern therein, and nithoatanydilatation protiraal to the lesion
S \ncoMA usually occurs m early life and shows less tendency to stenosis of
tia — Clironic olMtniction in Ihc •rruilt iitlenlim from a cnmnomA of (ho excum The
ilciim H croe^h <1 Iatr<l an I on cboioal examination a ntarke<l h^-po^nstno eplash could be elicited
v’Aie .tlip.u Alofy> J/ HontAtuWi? i>r/iwtu*s ^AUiwuilated ap
enrlj stage
CHROMC ILEITIS
Tuberculous Ileitis occurs in two forms, ulcemtiie and li\pertrophic
The nicerotne type is u>iunll\ secondary to an active tuberculosis focus
el«eitliere e g the lungs Tlie disease begins as an ulceration of the Foyer’s
patches m the lower ileum The ulcers tend to spread m an annular direction,
and suWquent cicatrisation producer multiple stenoses of the Tf to m
tins fatter stage that it gi\cs radiographic evidence of its nature
\ R n— N
210
ALIMEXTARY TRACT
filled lumen been to be irregularJj contracted, the contracted areas remaining
constant on rejieated examinations As the obstruction becomes more marked,
the bowel abo^e dc\ clops the picture of chronic intestinal obstruction already
described Since the radiographic appearances are not e\tlusi\e to this
condition tlic diagnosis ultimately rests on the evidence of active tuberculosis
elsew here, the demonstration of tubercle bacilli m the fscccs, or the appear-
ances at operation
Tht hypertrophic form is desenbed under ileo crccal tiihcrculosis m the
section on the colon
Plastic Ileitis {syn Regional iletlis, Crohn’s disease) — Crohn, Oin^ury,
l-ii. 1 130 Ik j 1 m<<>n 7 bouis afur a (mnum mR<iI cnit-io unknown
and Oppenhetnicr gave n full account of this condition in in32, a hteriosing
and plastic ileitis of the last foot of the ileum
Tlie caii-e of the condition which usually afilcta young adults, is unknown
CriNicvb FtATi nts — The terminal ilcum alone is involved Tlio disease
licgins as n suhaente or chronic ulcerative ilcitis, and procccils to steno-is
Fistulo? mat develop opening mto the cseciim or colon 'Ihc process involves
the ileo c ecai junction, hut not in the first place the cjeciim, and is most inarkc*!
at the ju\ta c'ccal {Hirtion The cour*>o is rclativelv lanign and iimiilites
chiuuiily an ulcerative colitis, with diarrhrra, and blood and mucus in tho
stools Some fever may lie present, and u tender mass may bo felt in the nght
iliac fossa
DISEASES OF IHE SMALL IXIESIINF
sn
Radiograiiiio Flatures — In the pre fistulous stigc tie bsinum enema
meals no abnornmliU but an oi>aquc meal «5hous a ^arjnng amount of ileal
stasis and dilatation nbo\e tbc lesion depending on the degree of stenosis
Tlie involved segment itself presents an irregular narrow ing of its lumen most
marked at tbc terminal end and an absence of peristaltic waves (Fig IGl)
\Mien fistulaj have formed deformity m the colon maj be seen from the
spread of the stenosmg inflammation to the colomc wall This maj cau»c a
i-ia 10] — Cri ] n « i t >1 ohemeototfecuna ] fUl U tlr nonljrosmat
iru svrrx* rolon x I o r m At p rt irp *1 ow ni; narrowed leum and St erl n » « cn n ea%um
n e « re mark-* tl e I n< r f U el n call
filling defect m the ascending colon or sigmoi 1 clo-iClj resembling a carcinoma
the fistula being aveounted a cancerous one f L Kantor in a report on
r c ists noted the j rchcnco of spasm of the r^uni (Sticrlm s sign) In a case
seen In the wTiter (Fig 162) tln<* contracture of the CTicum was partly spastic
and j irtl^ organic T1 o bxnom mial r 1 owed marked nirrowing due to both
factors and a suWquent barium enema the le^Mjr degree of organic con
trntturc the spasm having rclaxctl Kantor also noted a string sign m
the afTecte*! jwrtim of the ileum and points out that this mav be double
212
ALDfE\TAll\ TRACE
when a fistuh has de% eloped due to Imnum in the contracted ileum and m
the fistulous trnck
DiFFLBLNTiAn DuoNOSTs — \ Rij diagnosis of this condition may be
difficult ow iiig to its re'iemWanee to tuberculo'iis and actinomycosis of the ileo
('•) {)
Fio Kl'* Cn I n K i Mims *>k & !■ p 161 a barium tnmia {il bhowa theinj laj
raTsl 1 “! ft n (si n »* frn) uml ( lui*l»wilrsrltjr© 15 nunule** Istrr after tl
relftxoij (Tl •< raM> [ roieil 1 toloeirall nn I Itaetenoio? eall> )
exc d region W hen (icrforation mto the colon has oi curred it is apt to
inistnken for cancer of the latter \iscus Ulcerative colitis Hoilgkm s dt-scTsc
h mphosarcoma and chronic liyperjlastic appeudicitis arc incntionwl as other
condili n*. « hicli may simuHte it and the true nature niav l)»* apparent only
f n the ofientuip table or on histolopcal cwminntion
CHAPTER XVII
THE APPENDIX
IlADiOLOo^ PLAVS Tio part in the diagnosis of acute appendicitis
For jears controaersj has continued over the radiological diagnosis of
chronic appendicitis and no finahtj haa jet been reached
It has follo^\ed its oUnical counterpart m fashion and out and has in the
past too often proi ided the aller of the dragnosticallv destitute It might
almost be said tliat "Mr Punch a nd\icc applies here nUo I Mhile this is an
intentional ha perbolc its object is to stress the caution which must bo exercised
in making sucli a diagnosis on radiological grounds alone In n certain i>er
contago of ca«je3 tlio X ray cndcnco is sullicicntl> strong to enable this to be*
done but more frcquentlj tlie signs arc less frank Vhen in doubt tend to
give tlic apjKjndix the benefit of it
TECHNIQUE
The npiwndix maj be demonstrated bj the barium meal and ba the barium
enema £ho former w tl e more gcnerallv useful for seaenl reasons Firstlj
bi tJio meal the presonoo of an organic gastric or duodenal lesion is confirmocl
or excluded sccondU the presence of ileal stasis from ohstnictive adhesions
ina> Ix! show'n, again the caecum is not usually so distended b} a meal as it is
by an enema and Ic'S chance occurs of the appendix being masked Appendi
cular and coical stasis are more s itisfactonly studied by a meal The enema
if the ileo crccal sphincter is {latulous may flow! tlic ileum and render it
impossible to see the appendix In certain cases wliero it is desired to tost
whether an irregulnriU of the appendicular lumen shoavn by the opaque
meal is constant or w hether fai}nrc to fill it is due to obliteration of the lumen
a barium enema may be of help
Tl t thorium double contrast enema has the ad\antago that if successful
tfiD cjocum IS rcfatiwfy emj>t\ and* does not' obscure the appendix ft xs
howeacr not always jmssible to fill the apjiendix with this method nor to
cniptv the c'tciim for the collajwcd stage It is particu? irlj aseful in cases of
rot ro t Tcal adherent ap^wndicos m which it is ^mpo!^slble to obtain a profile \ lew
lor the barium enema the writer uses no special aanation from the stan
dard ofwique cream Canons special media baac liccn advocated such n.s
nrrowToot and buttonnilk it Ixnng claimcil that they ensure filling of the
apivciulix m a larger percentage of cases It is \er\ doubtful whether they
have the slightest cfTect in this respect or that the\ are worth the trouble
of prciviratiou
214
ALDIENTAttY TUACT
Accortliiig to KerUy the Camhea tccliniquo is 8uc<cssfttl iti MSiialising tie
normal api>endi\ in ne'irlj 100 per cent of cases This consi-^ts in gn mg bj
mouth three hours after the meal a concentmted saline solution such ns Mag
Sulph 1-2 drachms lu 3 oz of water
Gotlheinere technique consists in gmng castor oil twenty four to forty
eight hours after taking the barinm meal Filling of the nppendiv is said to
occur in a large percentage of cases a feu houiis after this procedure In
Mainyot s hands this was a Jess successful special teclimquo than CamOte^
hor tlie examinvtion of tlie appendix the meal sliould he taken in tlie
morning and the stomach anti duodenum first iincstigated The patient
should sub^equentlj he seen at se\cn twenty four and thirty hours after
tai mg the meal and on subsequent days as neccssaiy
The se\ tntli Jioiir is of importance in the detection of ilcil obstruction and
to show the relationship between the appendix and ilciim ^oinetimcs tie
normal npjiendix is not filled at the serentb hour but it can usually lie seen
at the twenty fourth or thirtieth Txamination on subsequent dath w nece
sarv only to determine the presence of appendicular stasis
Careful fluoroscopic palpation of the appendicuhr icgioii is an owntnl
procedure at eaih stage The patient should lie supine and the abdomen
well relaxed
Ihe follow mg points require attention during tins fluoroscopic exammation
the position nnd size of tlio appendix its mobibty the contour of it« lumen
w ith particular rcfercnw to kinks and stenoses and tlie presence of temlcnicM
on pressure oter its sliadow
In addition to fluoroscopy radiograms sliould be taken at each stage
Pressure may lio necessari to separate the appendicular from the caial and or
ileal shallows For this pucjtose the Iwst instnimont is the patient s left hand
The exact position and degree of pressure is easily determined fluoroscopically
The patient is instructed to relax the band and re apply the preasure sei'cml
times to make certain that the same t«eparation effect is achio\ed each time
nicii the patient s hand still lem lining m tlit- same position the film is pLaccil
m iwsition the pressure reapplied by the patient and the evjiosure made
The shadow of the patient s band is nearly al«a\s to the left of the CTC-il an 1
appendicular shadows and docs not obscure them
FILLING AND EMPTYING OF THE APPENDIX
There is doubt as to the precise mecharweiw of filling The pce\ ailing ' ic”
IS that filling of the appendix is a passive phenomenon except for relaxation ot
the sphimter It occur** with most ccrlointv at the timt of mnxinniin filin'?
of the creum and max bo present at nnv tunt lietwecn two and twenU fiu”'
hours after ingestion of the meal If it lias not filled in that time it unhke '
that later i-tages of the oxaminatioii will fiii<l it Msible
THE APPENDIX
215
Tiie cmptjmg of the apiientliv is ‘in acti\e jicnstaltic function It is
Kometiraes possible to observe the phenomenon of empUmg dunng screen
examination — usuall) m the form of a change in the appeanuce before firm
rachoscopic palpation comparc«{ with after In tins case the emptying mn> be
the result of direct pressure Apart from palpation it is not possible to make
out nil} change fiuoroscopicalh Senal radiograms do lioweacr reveal
changes m contour mdicatiic of penstaltic acti\it\ A not uncommon
npixiarance is segmentation piuduetng a tosar} cfiect The importance of
>io !0l — Nonnal npj en I x
dinercntmtifig muscular from cicatncial constrictions w obi lous and indicates
the necesfiit} for rc-cvamination at sueccssiio mteraaJs
NORMAL APPEARANCES
liie clas,Muil npi»cnraiice of the appendix in a lianum meal is that of a
iWtiv? fft’iu- 5 ^cf ■»' ima\vx AT Aaigi’A .WinfiWvs?
single or double cunc (Figs 163 165) From this prototape there may be
markcil aariation m man} respects Its length mn} aara from J inch to 9
inches Its lumen nn} be represented b} a mere thread of barium or be 5 to
t mm mandth Quito acute angulations maa Ixj simulated in a foreshortened
aicii riie lumen cla-ssicalla uniform m calibre inaa l>e shghtla narroner
toainrds the hise A more important variation m this respect is tliat clue to
mu''euhr contraction Such narrowings are inconstant
The n]»i)oii(h\ should ncirmalK be frccia mobile on jialpation hut if the
caxum be ix>l\ic m site it maj lie inncccs.ddc to such manipulation • The
21C
ALIMENTARY TR\Cr
position of the oppenih>: is norznnilj \erj vanable It is most comnionly
found I3 ing to the inner side of the c£ccum, hut maj he behind the cuaim to
the outer side of it, turn up-
wards to the hver, or hang
down into the pelvis Tlio
appendicular mesenterj maj
be very sliort in whicli case
the mobility of tlie appendix
IS restneted
CHRONIC APPENDICITIS
Pathology
For a proper a«ec sinent
of the value of the vinous
abnormal \ ray signs ob
served in and round the
appendix it i- important to
have sonic appreciation of
the pathological conditions
vvliicli may bo present
(1) Tlie nincosa iniv
m a thromc catarrluil state
F,. ir Ifitistrilemitoiis tliclumt..
Iht tij Tl r organ uHS M^ii te on(> on <i <ipUcrmenl of u ill be narrowed
llourn lal jloiim ihe ol «oncr ^ gIo\» Mian I {2) Repeated attacLs 01
appendicular catarrh tend to
civile fibrosis of Ibo sulmiucoui and inuiuilar coita This ciuses local or
general steno'iis of the lumen and Jesiiciis the peristaltic activity of the organ
(3) btasw of the ipi»endituJir contents from such stenosis often results m
the fonuation of focal toncretioiis TIicm? m turn tend to promote further
catarrhal attacks
(4) The pentonenl coat may betome inflamed and aa a rcsnll the oppcmlu
lieconie adherent to adjacent structures It may l>e adherent in its middle,
taitsing a fixed angulation or by its tip A tvpiral adhesion is that of the
apjieiicliculir tip to the adnexa In the controlling appendix
apjicndix is adherent to the terminal ileum and acting hke a bind causes stasis
in the ileum proximal to it It is iloulttful if a ebrome appendicular lo-ion
causes ileal stasis apart from such meclianicni factors
Radiological Signs of Chronic Appendicular Disease
Xo one sign is jvithognomonic Almost everv one of them is susceptible to
two interprctatioas — as a normal vanntion or ns a jialbologwAl condition
THE APPENDIX
217
The probabilitj of an organic change being present increases m direct ratio to
the number of the'^c mdmduallj dubious signs detected The probability is
further increased if a subsequent examination shous nn unchanged radiological
picture In other words constancy in an abnormal feature is an important
indication that it represents a pathological cliange
"Many signs have lioen dcscnlied Among the more inhercnth reasonable
of these are the followang
(1) Non filuno op the Appendix — This nia> be due to fibrotic stenosis
of the lumen The fallacj is that a certain small percentage of normal
appendices do not fill and tint the
healthj appendix fills and empties
itself at intervals
(2) iNCOStPLPTF FlLIlXC —
Uhere onlj part of the appendicular
luratn IS filled it is nceessarj to
determine if possible whether this
IS due to stenosis of part of the lumen
or an emptj phase in the nppen
dicuhr ejele of activitj Again
part of Its lumen may alrendv con
tarn transparent contents
(3) AtirXPTCTJLAnCONcnETlOXS
— Some of the«e contain phosphorus
and calcium and so cast a shadow
the niajonti are transparent The
former arc M«iblc m a plain radio
gram and are liable to l)c nnstaVen
for an} of the folloinng urctene
stone renal stone gall stone phlc
bohth TIic onij positive proof of their nature is their demonstration in a
I annm-outlined appendicular shadow Thej cast a lighter shadow than the
barium and therefore show in semi relief Shot from game and barium from
a previous meal are easily recognisable The transparent concretions are
cxiwpoiPiJxJ of fiTfpfssafevi /afces- amt atiT Im? otrfj uA'crt fAv apperp^r-f is-
filled wath the opaque medium when thev si ow os an oval gap in the appendix
shadow (Iig lCr>)
(4) iRnLoi LARm OF Till Appr^DicuLAn Lemen — ^To be of oiganic im
port an irregularitv of the hanum filled lumen must l>c constant in a senes
of radiograms Tins can bo tested at one seance b\ firm radioscopic massage
of the appendix lietwccn tlic taking of two radiograms Variations due to
muscular tonus arid pcnstabis vnrv , tho<e due to fil rojus do not Even if
this test produces no change it is as well to ehctk it on a subsequent tlav or bv
means of tlie banuin enema (Tig 167)
iio IGC — Chron append ct Tlpoppcn
d X c(»nt« nc«l a term nnl eonercl on showtsl nn
In 1 an rlub derorTTut\ and wa. a Iherent to
the creum
218
ALniENTARY TRACT
(5) FrxATiON OF TOE -Utevdix —Tins u»«all> indicates the prc<tence of
adhesions and should be tested fiirlj Mgoroush as it sometimes requires
considerable pres'suro to dislodge a mobile appendix Tins applies particn
larlx to one uho«e tip lies in
the pelvas Rareh the fixation is
due to a short nieso appendix
(C) Fixation of the Cecum
IND/OB iLEUii— This results from
peritoneal adhesions except m the
rare cases of anatomical fixation
Ino tvpcs are worthy of mention
In the 60 called controlling appen
dix desenhed bv /xine the
appendix is adherent acro-^ the
tomimal ileum and not onlv binds
it down to the postenor abdominal
wall hut causes ob«tructi\e ileal
stasis ■\Ithough Lane regards it
as a common occurrence m the
svnfers expenence it is rare (Fig
1C9)
A commoner type of adhesion w
that of the last few inches of tie
ilcum to the inner bonier of the
CTcum Tlie api»ndi.x usually hes
somewJiere m the angle hetvrcen
these two structures and appen
dirulnr mfiammation is therefore
prone to excite adhesive pentonesl
reaction on the two adjacent xi cera
Tlie resulting adherence is vi-ible
mdiograplucall^ by the close ap
position of the baniim filled c®cum
and ileum oven on finn jwlpation
The appendix mov l»e trapped
between them or adherent m fmat
orbehmd Inanj ofthesositiistions
It iim\ bt imiK)Si.ibIc to sec it until tlie ileuni is emptj
Pitholopcnl fixation of the ctecuni or ileum to palpation i*
<\idcncc on!} of pentoncal adhesions This mas o" nia\ not
np|iemh(ular in « ngiii and lias a significance with refcrcnct to an
npi>eiuhtii!ar Icsh n onh in the pre>.ence of otlier signs pointing m tie
same direction
Fm IG Vppm III H llifrrnt at il4 1 1 at
an 1 "*4 Ikjum after <1 a i -a] \t both exanuna
t otw tie ij iin >ob le on r»do«c«»pe
tutipat o
220
ALIMENTARY TRACT
(7) Iendernfss on I’ress’Ofp o\£ii THE Ateexoicui^r Shadow —nit.
nmj be asign of considerable importance and its significance depends on several
factors If tlie appendix is fixed the tenderness induced by pressure over it
probnblv usually depends on a drag on the parietal pentoneura Tendeme«3
o^ era mobile appendix is elicited b\ deep pressure with onefingeraccuratelyovcr
the appendix and should be obtained mth the litter displaced into different
positions This tenderness localised over the appendix shadow no matter
what its position and oxer its shadow only forms an important sign of chronic
appendicitis Hurst regards it as one of great value and explains the pirn
elicited as being due to increased xnsceral tension in the organ This presup
po'ses fcorae damming back of the contents m the appendix Whatexer the
mechanism the sign is the nio«t
reliable of ill the \ ray exidence
It must be elicited and localised with
careful precision Vague general
tenderness on pressure in tlie right
ihac fossa is of no diignostic im
pottince Many jntients are scnsi
tixe to firm palpatory pressure m the
lower abdomen and in these the
corresponding area on the left side
should also he palpated for com
panson
(8) ArrFXDtctrLAR Stasis— R e
tention of banum in the ap]iemhx
after the ciecum is clear is regartlcd
by Kadmla and others ns indicative
of appendicular discisc Tlio longer
the apjieiulix retains barium the
more important is this sign If it
retains barium for three or four dxvs
after the CTCum is empty of the
opaque medium % fibrotic or stenotic
lesion of the ajipendix i-s probable The importance of the sign is obviously
enhanced by direct exideiice of lumeiiol stenosis and diminished hy the demon
slmtion of a normal contour (Fig 170)
(n) Ii E.XL Stasis occurs in chronic disease of the appendix if adhesions have
formed of such a nature ns to cause some mechanical obstruction or if the
appendix itself is Iwund down by adhesions over the temunal deal loop
Aironling to some authorities it may abo result from reflex closure of the
iIoo-cTcal sphincter Vjine doubt exists on this point Lauc and Jordan
have made a prolongctl stiidx of this and for years ilcal stasis was reganle<l as
an important sign of appendicular disease A tcndencx also arose to find ileal
tio l"0 — y] pen 1 culHrfilti.11.4 Ilanum res Juf
t n (Inva After a b mum n cal
THE APPIADIX
221
staaia where none existed These authonties attnbuted the stasis particularly
to a kmk m the juxtn caccal loop but thw kink is now genemllj regarded
to bo nuich rarer than thej held it to be In the wnter s expenenco it is
cxtreinclj rare
In the estimation of ilcal stasis there is considerable ranation amongst
dificrent obser\ers According to llnral the ileum is iiauallj clear of barium
four hours after the stomach is completelj emptied but this time factor may
be longer in some cases Jordan Injs great stress on the fluoroscopic obsena
tion of wntl mg iKjristalsis m the ilcum a phenomenon mrelj met with in
the experience of others Dilatation of the last few loops of the ileiim may
be of significance but again the normal may show considerable venations in
this respect
In the writer s opimon considerable latitude should be allowed to the ileum
m tl 0 determination of stasis tlicrcm and stasis should be diagnosed in
the ab once of an obi ions constricting band oiil} if the ovidenco is frank
1C Considerable prolongation of the time mtcriaU considerable retention
of banum and definite deal ddatation
(10) Oasthto Stasis — Barcfai/ has described an ileo gastric i-cflox in which
ileal stasis from di«ensc in the appendicular region causes a reflex inhibition of
gastric evacuation inth resulting stasis As gastric stasis can bo duo toiu)
main other causes Us \ahie as a sign of appendicular disease is slight
In general chronic appendicitis is a condition in the diagnosis of which
clinicil evidence is ns important ns the radiological if not more so
LOCALISED APPENDIX ABSCESS
It M scMom that opiwrtiimty pre cuts itself to examine this condition
radiologies!!^ since the condition usually gives decisive clinical si^ns In the
iiioro chronic cases however doubt may exist m the difTcrential diagnosis
lietwcon nl scess carcinoma and tulicrculosis of the c'cemn These absce^'ses
ma> V arv in size from a hazel nut to an orange or larger When they reach
an} appixcinble stzo the^ cause a pressure defect m the banum filled cTJcum
innjbc an irregularity of tbe caeca! outline from associated typhlitis a fixation
of the c'ccum spasm of the CTcum (Slierlms sign) and tenderness on
jialpation
A Btud^ of the thorium relief pattern shows the mucosa to be intact This
dificreiitiatos the absces.s from the other tiro lesions mentioned above The
colonic mucosa ihstal from the abscess may show bv tlio same method a state
of reflex reaction or irritation
CANCER OF THE APPENDIX
This cannot be diagnosed rndvographuallv m an carlv stage An) radio
graphic signs present in the earh «tage are thaso of an associated appendicular
ALIMENTARY TRACT
222
inflammation When tlie grouth has begun to implicate the ileum and caicum,
the radiographic appearances proper to carcinoma in tliose situations will then
show tlicmselves
DIVERTICULA OF THE APPENDIX
These are rare, and occur along unth, and part of, a colonic dnerticu]o«is
Theoreticallj they should be prone to inflammatory changes, being, as they are,
blind offshoots from a narrow blind tnlie but on the other hand Loelhari
Mummerij states that inflainmator> changes are rare in them Cases have
been recorded by Btrg, Albrtcht, Kadrnla, and Saraztn The writer has seen
one case, found in a normal appendix dunng a routine examination
CHAITER VMII
EVAMIWTION OF THE COLON
The foi lowing methods are available
(1) Plain radiogram
(2) Binum meal
(3) Banum enema
(4) Biniim air double contrast enema
(5) Thonum^air double contrast enema
THE PLAIN RADIOGRAM
The radiognm is> used to studv the presence and distribution of gas
and fluid m the colon m ca*>e^ of auliacute and acute obstruction
THE BARIUM MEAL
The barium meal followed through till the colon is clear is of particular
value when the function of the colon requires investigation Occasionillv it is
permtssihlo to start this examination njvcn hours after the ingestion of the
meal but m routine work this is inidn<able unless it is quite ocrtiin the
upper flhmentarj tract n> witlurut fault Conrciucnkmterralsforthoetsmun
tion are «evcn hours after t!»e meal tnentv four hours thirtj hours and on
sub’jequent davs as is ncce^sirv The examination may extend over a vreek
or longer e‘'pccjall^ in case*, of chronic constipation partial obstruction and
dncHicuIosis Bariiun sulphate has a tendency to cake and form sc^bala
if retained too long in a colon and this mothoil sliould not be emploved when
there is reason to suspect organic colonic ob traction of nn^ degree In such
a case acute obstruction might be precipitated
Fi\n)roscopv umf ratihigrapAj ure iWiV sRK.em‘ari' Aronvr siluocAf 6e
conducted with the patient supine the latter in the supine the prone and
sometimes the erect pasition
THE BARIUM ENEMA
The barium enema is the sheet anclMir in the \ rav investigation of colonic
morpholog) Tlie banum meal verv frequentJv fids to outline the colon
sulTicientlv for a moiphologicnl studv Bv the opaque enema however the
colonic lumen can be complelelv outUnod
224
\LIMrNTAR\ TRACT
Preparation — here ate two desiderata tn the preparation for a hatiura
enema tlio colon must lie voided as complete!} ns possible of its contents
frecal and gaseous and the means taken to effect this must not leave the colon
so irritable ns to pres ent reasonable retention of the opaque enema diinng the
examination Castor oil 1 to 2 oz is the most generall} satisfactor} aperient
It should he gn en on the daj before the examination If the patient is in the
habit of taking some other aperient a double dose of that may suffice If the
bowel IS not thoroiiglil} cleaneil out bj this means a small soap and water
enema on the mormng of the mcainination may further stimulate evacuation
LftviaH% colonic lavage la ncccssav} It should be gi\eu two howr^
4 10 171 — Normal (olon c in ic<wal pittcrn 7 I oura after a banum meal
liefore the examination to allow time for absorption of fluid retained in the
upjier colon The Stiula chair in the best method for this
In cases in which there is cbiiicall} a strong suspicion of chronic obstruction
of the colon vigorous purging is unwise and unpleasant for the patient It is
better then to rely on colonic Hxage The latter procedure will empty the
colon ns far ns the point of ob*>tnietion which is all that is necessary for the
satisfactory demonstration of the obstruction
The Opaque Medium — Hie formulie which the writer uses are gi'enouHS^
35 It ehutild be as thin as fxissil le consistent xvith proiior siisjiension of t ic
hnnum sulphate Considerable variation occurs in different brands of I nntim
in tins res|)cct ^\^th some specimens the particles arc so largo that a con
EXAillXATIOX OF THE COLON
225
Bidcnble quantitj of mucilage is ncw=«arj to hold the banum in proper emul
‘•ion, and a thick cream means undul\ sIott filling of the colon Tlie colloidal
preparations of banum sulphate now on the market mil staj in suspension
for one half to one hour, and may he uswl without any suspending agent
They ha\e the adiantage that the muco al pattern is better sho^Ti after
evacuation and arc particularlv ii««ful for tlie three stage banum air
enema Tlie emuKion should be •\\armcd to blood beat before ndmimstra
tron Several pints of cold fluid introtluocd into a colon is unplea«ant for the
patient and promotes a peristaltic reflex in the gut As much as 4 pints may
1x5 ncccssirj to fill the colon and this amount should aUvays Ixj available
Apparatus — The following ncrcssofy appliances are neccssaiy
(1) A large glass funnel enpaWe of holding 2 pints The usual flat bottomed
metal douciic-can is not satisfactorj as banum fends fo form a sludge at the
foot In addition it is diflicult to sco from it the rate of administration An
inverted hot water bag with the stopper pierced by a hollow metal tube is
quite a convenient reservoir
(2) home simple form of stand to support tins
(3) \ length of large bore nibbcr tubing This is conveniently interrupted
bv a glass connecting tulic
(4) A strong spnng clip or stopcock to control the flow The stopcock
may with advantage 1x5 three wav, with a side tube for evacuation
(5) A rectal tube The opening in this should Ixi terminal or close to the
end and large A largo size cc«opliageal tube serves but some fonn of metal
self rotaming enema nozzle is more satisfactory
It 13 of vital importance that the whole apparatus of administration bo
stcntiscd bv boiling or other agent lietwcen each examination ns the same
tubing is used for evacuation of the enema and thus becomes contaminated
Administration — ^Tiie patient is arranged on the couch so that the observer
IS on his left The rectal tiilxf eniptv and separate from the rest of the system,
is first introduced and tlio patient placed in the supine position Tlie tube
should be sufficiontlv long to reach down under the thigh to the patients
side The reservoir in position on its stand and the mam length of tube are
then filled with barium down to tlio glass connecting piece controlled by the
cl^fi or stn.ncock Tlie^lflss connection is thenjoineii with the rectal
tube and tlie enema ready to be run in Tins method involves introducing a
small amount of air — the amount m the rectal tulie — but tlus objection is m
the mam ibeoretlcal and the advantage — that of n clean, dry admimstration —
verv practical Another iwmt m its favour is that the ^c'^;^volr is not fillwl
until just liefore the enema is nm in and thus the barium has little time to
Fctbmcnt and bv so doing clog the tube
Xbe disadvantage above mentioncil max he mimmusetl by placing the glass
connecting piece as close to the rectal noialc as possible The enema is then
run in slowlv bv gmvitv the whole process being observed fluoroscopically
\ It II — 15
ALBIEXTARY TRACT
It IS important to instnict the patient oji three points narael^^to make
c\crj effort to retain tlie /?nema to saj if he experiences pam or discomfort,
and to give vrarmng of on impending IcaUagc past the tube A flood of banum
on the \ mj umcli is qiute a deiastnting occurrence for all concerned (par
ticidarl 3 for patient and nurse ’) It can he foretold bj anj intelligent patient
its 1 eginnmgs ob«cr\td on thescrecn and ita progress arrested bj relieiingthc
pressure orcmptsingthe
rectum of a feu ounces
vtn the rectal tube
As soon as the rectum
IS filled out to its normal
‘ wide contour the patient
IS apt to expenenco *1
desire to eiacnate It
Ls advisable then to stop
the admimstration for a
feu seconds until tins
passes off In the
mnjoritj of patients the
u hole colon inaj then he
filled uithout further dis
comfort but m some
intermittent adimnistra
tion is neccsiary because
of recurring distress
Fnch portion of the gut
I should bo carefully m
I Hpected and palpated as
' it fills and rotationofthe
patient into the oblique
positions IS neccssarv to
view 8ui>cnmpo^l ooib
. . Ill their enliretj.particu
ric 1 IlftT inciona nonnalcoinn «fi»earan c . , ,, j -_,I
“ larh m the sigmoid and
splenic flexure
Radio„ranis should be taken dunng the lilhrig if nn\ ejiecial jKimt uarrants
and routine supint prone md oblique %icws after complete filling Tliciviticnt
IS asked to retain the enema uhile tlicM? ore deielojied and inspected in ca^
the\ rticnl some point requiring further investigation Most patients can <
this but if am distress is expericnceil it can as a nilc be relieved bv empt^g
the rectum onlv and vnthout dutturbiiig tho general filling of the colon Tlie
enema is then run off as far as possible Usually onlj a portion can be rtturne*
in this manner This process can be aided somewhat by pressure on the hvpo
J73 — Normnl banum onema B|>j>eftrancp
228
\LBmNT-VRl TRACT
gastnum A fiirtl cr radiogram maj then 1 e taken or after tl c j atient has
retired and rel eved inraself m the normal maimer IJic mucosal pattern
I' r 1 u — 'Sornial colon artrr ctbc at on of a l>anujn enc m Th « p ct TO I y chai ce*J O'**
tl o opp ars cs n the tl ree slagM of a bar n a r me ua from cu'cum to s intio d «ro seen
1 Ihejl al I attem n collapse tl o contour lino in nllat on and 3 tlobar mUBcl'
raaj sometimes be seen at this stage but m mnnj cases no satisfactorv view
of it 13 obtained
THE BARIUM AIR DOUBLE CONTRAST ENEMA
lliis mnj give an excellent picture of tl o nonnal colonic mucosal jvittoni
but IS mtl er a I ng process nn I lo not oln i\s Ruccessful Tl e appearance o
EXA’\ID?ATION OF THE COLON
229
the normal pbcaj is similar to that described later m the tlionum three-stage
enema, but the abnormal plic'c arc more erratic in their demonstration than
ivitli the latter medium Frequently the barium fails to coat the imico«a
completclj The method is of particular value m the demonstration of small
pedunculated groxrths A’tr/hn recommemis its use on oH cases of colonic
haemorrhage in ivhich the onhnary banum enema Ins fnle<l to reveal any
organic lesion The technique, os evohed by KirUin is as follous
The preparation is all important, and must ensure complete evacuation of
the bon cl Two ounces of castor oil should bo given on tlie day before, and on
the morning of the examination saline colomc lavage is gi\ cn until tlio return
13 clear
\ftcr the ordinary barium enema examination Ins been completed the
patient retires and empties the bond as far ns possible On his return, a
radiogram is tahen of the collapsed bowel in tiie hope of shomng the mucosal
pattern There is more chance of this being achieved if the “colloidal”
preparations of barium arc ««ctl Ulie colon is then filled with air bj a
Higginson s syringe This in turn induces a call to stool The patient again
retires and the process is rcpcafctl until all the banum has been evacuated
except for a tliin layer coatmg the mucosa Two or three insu/flations may
bo required to elTcct this After a final air inflation stereoscopic radio
grams nro taken These show the gos distended colonic walls standing out m
relief and a barium coated poly poid tumour can clearly be scon projecting into
the lumen A scybvloti presents a closelv similar appearance, honeo the
neccsaitj for very thorough iircparalion
THE THORrUi'f-AIR DOUBLE CONTRAST ENEMA
Because of its simplicity , the barium sulphate enema remains the standard
method of examination of the colon, but in certain cases of ihfRcuIty an
investigation of t!ic mucosal pattern by flocculcnt media may be helpful This
!«, a V ariant of the banum air double contrast enernn method descnlied above,
and the examination «i tins case is aUo in three phases (I) the filled colon ,
(2) the collapsed colon showing the mucosa coated by flocculation of the
opiquo medium , (3) the colon dtslcndetl by air
ITAi? AWviWvVf iw i*A\p d'Sff ftvavw Ssr tXw ti iftaamvle
tion docs not occur, and the coating of the mucosa is very incomplete Tlie
labile colloidal susi>ensions of thorium oxide if used with proper technique,
depo’^it thcmsclv cs more satisfaclonlv on the surface of the imicosa and bo out
line it Three prejurations arc available, «q far — coflolfor, umbralfior and dia^-
nofhoritu' — and all three have a common characteristic in tliat they arc rapidiv
precipitated or flocculated by onlinary water Thorotrast, being a stable
form of thorium dioxide, does not floociihle and is nnsinf ablo for this piiqioso
Flocculation should not take place too rapidh, othcrwi o the depasited layer
may lie too thick, not sufRcientlv elastic, and the upper reaches of the colon not
230
ALDIENTARY TRACT
reiclied It dcpciula on t\ro factors, the exact prepanition itself, and the pll
of the colonic interior
Briefly, a lugh pH indiicca the dcpo‘»ition of an elastic lajer, Avhich r^idJv
stretches during the subsequent insufflation, « hile a Iok pH produces a floccii
lent Isjer less \ iscous and more apt to fragment during imufilation In theory,
it might be possible to choose a medium suitable to the ascertained pH of the
colonic contents in each case In practice it is simpler to adjust the latter to
tlie medium, dtiruig the preparation of the patient by tlic use of colomc he age
■\% ith a solution of sodium phosphate in a strength of 10-20 per thousand The
alioie three media act best, on the average where the colon has been washed
out one liour before with this solution Diagnotlionnc, the medium used bi
the WTitcr IS sold hy the makers m a strength of 23 per cent and should be
diluted to the appropriate strength for use (5-10 per cent ) with diiliUed water
Tap water will cxusc an immediate precipitation
Preliminary Preparation — Because of the biophysical factors inioUeil. tliu
IS of the utmost importance The colon must lie coniplcldy emptied of all
seybalv and other contents and the mucosa cleansed of adherent mucus etc,
and its pH adjusted
Maivjot recommends the following preparation
(1) On the evening lieforo the examination 1-2 oz tastor oil followed hj a
hquid diet up to the time of the examination
(2) On the morning of the examination colomc la\age with plrin water
two hours before and with the aboie solution of sodium phosphate one
hour lieforc
'>nbno purges and drastic cathartics are madvasable, since they imtato the
colon and cause hyT>encmia and hyqiermotility of its mucosa Even castor oil
docs this to a blight extent
The Injection — ^The essence is to u«e as little of the opaque medium as
possible distension of the colon is to be molded The administration must
therefore be intermittent Matnyot and hia co workers use a special air
pressure apparatus delnenng a full strength or half strength solution at will,
In the absence of such apparatus the solution may be admimstcrcd by gravity
using a glass funnel and tulie or by a Higginson’s syTuige Wiichever method
!•» used about half a Utro is sufficient to fill the whole colon The filling should
bft. 9.'My:eaie;y?.'i'Z.U5 wv/1 'sttK WKust ttvw. k-1 wi. al a time
One must avoid distending the rectum as it may not contract satisfactonh and
so retain too much of the medium In this examination it is undesirable to
stretch the tonicitv of the colon Usually the colon fills satisfactorily* as far <ls
the right half of the transverse colon, but it is often difficult to fill the n^t
colon Any attempt to increase the pressure of the injection mast 1*0 resisted
luming the patient on the side and on the face may bo successful Patjwforj
pressure should lie guarded against, lest a mass peristaltic wave is induced
Mhcn the colon is fillet! to the csccura, but with its lumen relatively con
LV^3II^ATI0^ OF IHr COLON
231
tmctccl the fir«t ndiograms are taken The patient sliouk! tlieii he still for
ten to fifteen minutes to allou flocculation to tike place He then instnicteil
to emptv the rectum but not to strain It is preferable to pa\ t«o or three
■visits to stool since it is si«l bj Jfatnffol straining mnj inclutc. secretion of
cxilonic mucus itul displace the llocculent la>cr As soon as the bowel is
collapf-cd there is not a itimuto to lose ance mucous secretion quickly licgins to
displace the flocculation The necessary radiograms should be tal en at once
and then the third, phase air distension inni be undertaken
Failures in the Technique of Flocculation
No Dirosrrros ma} take place at all In this ca‘*e it is licst to postpone
re-ex«mma(ion to a subsequent date to repeat the prepintion ‘vnth thorough
care and to use a stronger colloidal suspension Immediate refilling with a
stroiic^cr fiiispcn'iion is less likelj to be successful
iRREruLAn Dirosmus — riocculation inaj take phcc sa^ in the right
colon and none m the loft 1 urthcr measures wall depend on the diagnostic
requirements It maj bo po sible to proceed to immediate partial refilling
with stronger suspension as in the case postulated In some cases the partial
flocculation maj give the nccc'^sarj information while m others complete
refilling on anotlier daj nm\ be advasable
iATLtnt to EsriT’a — ^Tho eracuation of the colon may be incomplete
This M prone tb occur m cl Icrlj subjects mid the right colon is commonly
the site of tho incomplete omptjmg Posture and alxloimnal massage may
Jiclp but are sometimes incncctnc Pitrcssin (S units) is sometimes oiTcctisc
but nmj provoke vigorous segmental jieristnUis and destroy the mucous
pattern -■ Prostigmme inaj promote satisfaetoiy peristalsis and in elderlj
patients and others mw horn colonic nionj is suspected 1 2cc ofprostigmine
maj bo given livpodermicallv with adv mtoge twentj minutes liefore the
Wgmmng of the examination
Insufflation of the Colon — As soon ns satisfactorj radiograms have been
obtained of the coliap>>ed mucous pattern (he colon should be insufflated prior
to the final radiograms This should be done under fluoroscopic control An
*m*i'ilaair«'t’awnwn\«.*j|wi’5rx<ri'q7!rrtri*fi3rgr»'rt-«rcaRVv«wvnwt4i>Uivg' ivivfo’
svTingp manipulated gently is a satisfactorv substitute
Certain difficulties may bemetwithdirmginsufllation Ideallv tlie whole
colon should fill regularlj from rectum to caecum but in most cases there is
some vanctj m the distnlmtion of gas and some of tho opaque injection
rctnineil \\ itli this one imist bo content
In hypertonic stronglv muscletl subjects it mav bo diflicult to distend tho
colon satisfictordv If the sphincters are patuloius retention of the injected
air mav be imposrsihle although the u o of a large rectal tube raaj help m
this rcsjiect
232
ALniFNTAUy TRAC3T
Radiographic Appearances in the First Stage, that of the Filled Colon —
llicse arc substantially the same as wtli a barium enema save that the colon
IS not so distended and the medium not so opaque (Fig 17C)
Radiographic Appearances of the Phcs m the Second Stage, after Collapse
of the Colon — A colon uall contract by virtue of its elasticity and muscular
>|f 1“ Norowl tl tfn im A r »tage«<nnii f rnt of filling
tonicita Ihe nnmmed lumen has to ntcommocHte tbc same mucosa andtho
latter folds it«elf into phca> (Fig 177)
rari-s Oh Pucmo>
(1) Ilav^lrnltons the whole wall being involved
(2) l/uco,sai F/iCfC— Tlic mucosa » \ccv laaU attached to the muscular
coat and can form \arying phex independently of the latter The phe®
WjVftwA&w eiwdUmc forw vanes inia
the degree of %asculant\ of tho siibmucosa the secretory activity of tbe
niiieoiis glands and other netaous and irritative factors
I’tlocarpmc contracts the gut and mcrea«es the number of plica: ttropiuc
has the reverse efiecl
Form of TUt. Puci
Longttudinnl foldn tend to take place when the tTnia are relaxed an 1 the
gut lengtlitnid llu\ are common m the lower sigmoid Transiersf phea"
EXA.^IINATION OP THE COLON’
233
occur when haustra are present. Usually both can be made out, and from these
primary pJIca? seconder}’ arborisations frequently arise (Fig. 171). As in the
stomach, so in the colon great variation in the normal mucosa may occur, and
in the present state of our knowledge diagnosis of the patliological should
bo guarded.
Pathological Variations In the Mucosal Pattern. — The pUca? do not form at
all unless the colon contracts and empties itself. At times collapse does not
Ktd la? — Xormal tlionum Air enemn Saxond bIbitp, of coIla|>«<
occur — air in tlio colon prevents it ; atony or hyiretonia of the colon above an
obstnictlou, and ngtdity of the colonic nail are other causes. Assuming that
collaji^e has token pkice and the opjiortunity for flocculation and plication so
piWaVaVtt’, .nn’it.wv raftwAlnw Av /Aw mwwspiJ .top/* Avidwp.tc
states. Amongst these variations arc the following :
PucjE Small and XotEnous. — Tliis h seen in the so'called “ irritahle ”
colon, a condition which Knofbe dcstrilics as a reflex disturhance of the
ncuro-miLscukir mechanism, eg. from tuberculous peritonitis, cholecystitis,
or apixjmUcitis.
Puc;e LvnaE akd Few in XusiiiEn — ^Tliis results from any congestion of-
the muccKa. ns in catarrhal colitis.
Pur.?: Smali., Simpli. iv Pattebv, A^D Few in* Xumdeh — ^This occurs
with atrophy of the m«cos.a
234
ALnirNTAR\ TRACT
Of greater diagnostic imiiortance than tlio abo\c art- certain other clianges
in tho nnicosal pattern mich ns
xVsTtiusK OR IIovticoMo PiTTERN in polyposia Tlio clear interstices
represent the poh pi In diverticulitis a similar star pattcni may radiate from
a filled diverticulum
Disoboavisation of the Pattern — ^lliis is seen m mucous colitis an! m
increased degree in earh ukeratne colitis
\nsFNCi’ oi Pfcicr — lliis results from grave destruction of the muco«a as
in 'idvsueed ulcerstwe colitis or neopl-\sm
i-io 1 S Nonnal tl or um A r •‘nenm 71 ni HtAc<> ormnat on
Radiographic Appearances of fhe Third Stage after Inflation of the Colon
■with Gas — Three asjiects in pirficiilar should be notcil the colonic calibre
the dilincation of its contours and the appearance of tho anterior and jX) tenor
nails hcen e» fare (hig 178)
Tuf Colomc Caubrf >%lH,n insuflWteil li lx:t%\cen tuo and three times
that nhen filled bv the thorium enema and about equal to or a little hr{^f
than that shown li> tho onlmacy kanum enema The lamtioas from the
normal arc similar to tho"*c shown b\ the banum enema and nets! no f^tl er
description here
Tiif tOMOi R Linf is of tonsidcrablc imjxirtance according to Mairjjo
Normally if the llomihlion and distension have ))Ocn successful the contour
of the lumen should be outlinetl bj a dark lino 1 2 mm thick uniform aiB
KX^MINATIOX or THE COLOX
235
continuous ^laingol and liH co workers laj such stress on tJns that they
ha\ e limned it the hsSre de aeeunte, on the hypothesis that if this line
IS present in unbroken contmuitj it excludes an uleeratis e colitis Its nbsonce
IS of less importance vmce defettx\c flocculation or excess of mucous ficcretion
maj pre\cnt its appearance orrajiidlj obliterate it, respectively
Ilic opaque contour hue mav be quite absent in niiicous cohtis hut more
commonly it is broken, ap^iearing like morse code symbols This also is
inconstant as a sign and may appear m the normal subject if the floccnlcnt
layer was too inelastic to accommodate to the stretching of the insufflation
Again tlio marginal lino may lie irregular or woollv, due to excess of mucus
in it In dncrticuhtis it shows a cJ»araefcria.tic api>eirance desorihed under
that section In intrinsic tumours and dc\elopc<l ulcerative cohtis the line is
irregular and broken at the site of the lesion
liiF Sniirvci oi TiiF "MiiCos^ seln ‘fn pace * m the area bounded
by the contour lines interniargmnl area ”) also merits attention Xormally
it should be uniform like a colour wash, if the flocculation has withstood the
insufllation ^loro commonly it cracks, and forms a mosaic, like the " crarmg ’
in pottery ware In this mosaic the “ stones ’ arc opaque and the mtcrscmng
cement la tr vnsparent In this intcrmarginal area various opacities may bo
visililo such ns the rounded shadows of filled diverticula and the irregular
blobs of impregnated mucus in mucous cohtis
llehcidahon may he ev ident, the appearance then being the negativ o of the
normal crarmg , i e the reticulum is opaque It is irregiihr in type and is
seen m developed ulcerative colitis vnth granulomatous proliferations
Pohfpoitf shows a remarkable ‘negative” mosaic appearance, the clear
spares representing the polypi Larger ones may retain a complete coating,
and stand out clearly in the air filled colonic lumen
Cnrcuwma shows a completely disorganised irregularity m the inter-
marguial shadows, and the unchanging quality of this deformity is an
important feature
In conclusion the thorium three stngo enema w a new method, and is not
infrequently unsuccessful The technique la difiicult, but further experience
may indicate modifications which wall improve the percentage of successful
adimniirtni'tioiis It appears at prcMint to \>e o'? v due ctnefty in cases oI co’iitia
and colomc ha'morrhage in which the older methods fuJ to give definite radio
logical sign^, and its precise value ns a method is yet to be finally assessed
CHAPTER MX
AXATOMV A\D PH\SIOLOG\ OF THE COLON
ANATOMY OF THE LARGE INTESTINE
liiE LARGE intestine consists of the can^uiu the colon and the rectum Its
nnatomv and genenl arran^ment in the abdomen do not need detaJcd
de‘’cnption except for some points of radiological importance Its arerage
length IS o feet and its Tindth ^ anes from 2 to 3 inches The Tndest part ls llie
CTCum and it gradually narro\n5 toicanls the rectum
The Cfclm the mdest and most dHteasible portion ■with the exception
of the rectum is usually situated in the nghf iliac fova but it is subject to
great variation in this respect depending on the length of its me^enferr anl
the habitus of the indmdual In hypersthenic subjects it mas be lugh up m
the fos. n and in luiw^thenics deep in the pelvis It is normallr freelv
mobile on palpation but in aliout «>iiercent of ca«es it po'^»e«^es no ine~euten
and is then relatively fixed This variation must be borne in mmd in tie
diagnosis of CTcal a<lhesions
The V^CEvnivG Colon is continuous with the ciccum andniiisiijiwartlsto
end at the hepatic flexure The ascending colon is said to liave no nie«entcn
and to lie bare of peritoneum posteriorly but m spite of this it di. plaas a
surprising degree <f mobilitx The finrard and metlial liend of the gut which
forms the heiatic iLrxrpE has no firm attachment above and its position
xanes markedh with posture In the erect position it is usually jii*t above
the iliac crc«t and in the sujune 1 2 inches higher
The PnANsxERsL (olon has n long mesenten. and is subject to great
variation in position It max pursue a rclatixely straight course between tl e
flexures or hang in a pendent loop into the pelvis
The bi LFxic Fi ex ms occupies a position lugh under the left dome of the
diiphragm It is in respect of its position the most con.tnnt part of the
upper colon being anchored ll ere bx the costo colic ligament Ocoasionalb
it IS seen lower in {>osition but this i-s held bx some to be alwax's patl ological
Indeed if there be anx true radiological sign of GlenanI s dL«ease it is marked
descent of this flexure
Titr DrscrsDixo and Iliac Pocnox'* of thf Corxix drop dowm from the
splenic flexure to tlu, truebnm of the pelvis Asa rule they have no rae-enttrv
but in spite of tlus considerable lateral mobilitv js normallx present Tliev are
the narrowest portions of the colon
Thf Pelxic Colox has a mesentery xrfiich when spread out curves fhep^^
•30
ANATOMY AND PHYSIOLOGY OF THE COLON
237
in sigmoid form. This portion is tiieteforo frcelj* mobile, and very varied in its
disposition. In some cases the moscnterj' is short, in others it is long and
alloTvs of a large sigmoid loop. At its termination it is directed backxrards and
then do\i mi ards to form the rcctosigmoidal junction. It therefore lies in front
of tiic upper part of the rectum.
Thk Muscular Coat of the colon w composed of an internal continuous
circular laj'cr and three outer longiturlinal bands, the tamia coh. The tonic
Fit. IW — Normol colon 7 hours aflor o bonum mo«[. showing Iho trefoil orrangcinent of tho
liaiutrAi fipckcis, duo to llm i]L^>osition of the tTiua colt
contraction of these bamls helps to form the baustral sacculations of tho
resting colon. These haustrations are largest in tho cffcum and ascending
colon, most regularly formed in tho transverse colon {where they may be
.v.Vtf.V.iwJAVftl*? AVw,tiwnaj-jx? ihwiV
baustral segment is tj^pically trefoil when viewed m cross section (Fig. 179).
FUNCTION OF THE LARGE INTESTINE
The function of the colon with whi<^i the radiologist is particularly
concerned is, in tho main, motor j its mcthwl of hlling, and its tonic and
jionsialtic activity.
This is best studied by the barium meal.
Filling of the Cacum and Upper Colon. — In spite of tlio countless screen
examinations which have l>ccn made on subjects and patients, this still remains
238
ALBIEKTARY TRACT
something of a injstery A colon is viewed, saj, two to three hours after a
barium meal, and some of the opaque medium is seen in the caecum Two
hours later, the colon maj be filled with barium as far as the middle of tho
transverce portion, jet repeated screen examinations during that inteiral
would fad to reieal anj appreciable movement m the contents of the gut
The explanation lies, I think, in tliree factors (1) Ihe regular intermittent
passage of email quantities of chjme from the ileum into the cfccum (2) The
fluid nature of this chyme (3) Tlic tomcitj of the bowel
M hen fluid contents pass into the caecum the tomcitj of the latter tends to
force them a certain distance along the colon, depending on the amount of
fluid and degree of tomcitj Thisiaavciy alow process andean belikencdtoa
veryslowlj administered banum enema so alow that the onward progress of
the head of the barium column cannot be appreciated The process is arrested
pradtiallj bj' the activitj of a function of the upper and right portion of the
colon — that of resorption of water As the contents become semi solid and
then pultaceous this onward progression ceases, and a different form of activity
takes change the mass movement
Mass Movement — ^Tlus form of jienstaltio ictintj first descrdied Iv
Ifohhiecht over luentj jears ago, is now accepted ns tJie only norma! mcthwl
of transporting the contents of the upper right colon towards the rectum
The term ‘ iipjier nght colon ” is coine<l to indicite that portion of the
large intestine in which the rcsorptive process takes place It extends
from the crecum to about two thirds along the transverse colon The colon
from about the splenic flexure to tho rectosignioidal junction is difTcrent m
function ^\hlle the former mij be regarded fi-s a rescrwoir the htter ns
GaslfU has described it is a transmitting segment of exaggerated imtabilitj
Its normal stale is that of emptiness llaustral sacculations the object of
which IS to incm«e the area of absorption, are poorlj marked in the left colon,
where the necessity for them is less Wlicnover a fvcal bolus is dehrered to
this portion over the splenic flexure, the tendency is for it to be swept down
into the rectum
To return to the mass movement tho sequence of events is ns follows
first of nil the liaustral contraetioas over a considerable segment of ssv the
transverse colon disapjiear and the bxnum shadow has a ribbon like outline
This change occurs v cry rapidly in two to three seconds At the same time a
constnction appears proximal to the fipcal mass, iisuilU m tho region ofd'*
hepatic flexure IhTclay has »lressc<l tho importance of this con«tnclion
which he terms the jioxnt d apptit, and is of the opinion that on its competenev
depends the successful transference of the fajcal mass along tho colon The
more liquid the mass IS the greater the importance of this to prevent rcHu*
into the lax ascending colon and cveum Tins constriction reallv mark* the
fitartiug point of the strong pcnstnitic wave which awceps the colonic
contents on towards the rectum Tho whole process is over in a short time
\KATOiIY iVND PHYSIOLOGY OF THE COLON
23 »
In about ten to twentj ‘seconds the mass may reach the descending or sigmoid
colon The ma«s nio\ cnient ninj ho arrested for a fe^r moments v. hen the diac
colon is reached and then continue until the mass is in the rectum
A few seconds after the reflex is completed haustral contractions reappear,
and as Jiarclay puts it the general picture of stiU life is restored
Not uncommonly a radiogram taken after a mass movement has taken
place uiJJehou a snail tmek of barium along the empty colon along which
the transference has taken place This is a common appearance in cases of
mucous colitis — Crane s string sign — but occurs also m the normal
In the perfect ph\8iological reflex the portion of gut im olved m the wave
should lie emptied completch hut frequently some fragments are left m the
wake Jins is particularly apt to happen if there has been a tendency to
constipation and formation of scybala
rhese mavs mo^emonts occur infrequently, two or three times a dn^, and
\arj in the extent of their travel ^me reach the sigmoid or rectum and
some the descending colon the mass left there being dealt intli b\ a subsc
quent reflex some hours later Only when the rectum is reached is a call
to Rtool experienced
Other Movements
JiiE PF^DUItr^t AIosemevt or Uiedcr — Tins ob^rver has described to
and fro movements of tJio contents of quite a large segment of the bowel
i ho object IS supposed to lie to chum the contents It is said to bo an cstab
hsbed phenomenon but it is extremely rareU seen Tlie writer has not como
across it m lliousands of screen examinations although be his oh erved the
mass nwyement on many occn«jons
Avrn miST\i>is — Case has rcconled cases of antipon&talsis m the colon
It IS posiihle that this oecuiv. behind an obstruction m the upper colon and
often occurs m a colon which is trnng to rid itself of a barium enema against
the patients wishes but it is doubtful if it occurs m the normal apart from
such forcible voluntaiy rcstmmt of dcrecation
llArsrnut. CiifTtvixc — ^This has been described b\ Snmwi WrtfjJit Cole
and others It occurs espeenlK m the cajcum ascending and proximal
transverse colon and consists of slow alterations in the degree of the haustra
tion Tiiev are too slow to lie detected with ccrtaintv on screen examiintion,
hut can he seen in serial radiograms
RATE OF TRANSIT THROUGH THE LARGE INTESTINE
Thi‘« vanes enormously in dilTercnt indivoduals and obviously depends on
the numlxT and extent of the mas'i movements which take phee m the twenty
four hoiirv Taking as a stnndnnl the subject who defTcates once a day, tho
rate of progress of a bnnum meal is somewhat ns follows
240
•iLLMENTARY TR\CT
In tJiree hours the CTjcum is filled in fire to sii hours the hcwl of the
banuin is in the region of the hepatic flesuro or proximal transverse colon , in
tivclvc hours It IS about the splenic flexure By tvientj four hours half of the
barium maj Inve been evacuated and the remainder rather scattered with
traces in the c-ecum and ascending colon and some m the sigmoid From the
distal position of the transverse colon to the iliac colon is usually clear B;
fort} eight iiours none should remain
In those of more nctiv e colonic liahit these times may lie greatly shortened
It IS not uncommon to find barium in tlie rectum two to four hours after in
gestion especial)} incircumstanccsofnervousstress ItwasIroimcoMwliofirst
dreii attention tothetendenej tohjpcrmotiht} and diarrhoea in the neuroses
\ more common octurrenre however h to find these times lengthened and
vihilo such a state of affairs is often labelled as stasis it u» important to bear in
mind that tint stasis may bo physiological
CH.\I>TER XX
ANATOMICAL VARlAnONS OF THE COLON
Ti[i SI- ■M bo classified m tlie following manner
Anomsties of length
Anomalies of rotation
\nomalies of fixation
Vnomalics of size
Anomalies due to adhesions and henna;
ANOMALIES OF LENGTH
The Short Colon, with high position straight gut between the fic\nre», and
a Binall sigmoid is of little clinical significanco mnee it is seldom associated
with physiological dtsfunction The wTiters impro'-sion is tint colospnsm is
ninro common in this type than m the hypotonic individual
The Long Colon, redundant colon, or dohchocolon of the continental wnterb,
is according to Kantor, frequently ofcsociatcd willi a cliiucal syndromo con
sistmg of constipation gn«cous distension, and nbdominal pain the aiito*
iiitOMcation of Arbiithnol l/ine (Fig iSO)
Kantor dc'icnhcs the following entena
The long pch ic loop n^es well above the mtercnstal line It may be placed
medially, or to the right or left
Tlie redundant descending colon is commonly coiled or reduplicated, the
t ransv ersc coloiwlecply festooned or conv ohited ami the ascending colondoubled
The redundant colon can cause considerable discomfort to the patient and
trouble to the radiologist if the up}>cr colon is di&tendcd with gas , to the
former by flatulent discomfort and to the latter by making gastric exammation
difficult Mhen distended with gas it can produce the various stages of
cascade stomach hiloculated stomach, and volvulus m both planes
Subphrcnic Displacement of the Colon (.SVa Hepato-diaphragmatic Inter-
position)
Frcquentlv the gas filled traimerse colon may be seen, m ca'ios of the long
avial gastric rotation crossing in front of the latter, and up lietween the hver
and the right cupola — the so called falciform colon (big 181) Graham
Hodgson m a personal communication rcconls a case in viluch the falciform
ligament was fmmil at ojiemtion to be absent This licpatoKliaphragmatic
interposition may be temporary , or mav become fixed The upward displace
ment mnv also lie posterior to the hver
\ n n — 1C
rtnlmliuii Ijpt
AXATO'MICAL ^ AEIATIOVS OF THE COLO\
243
A VICIOUS circle maj bo established in thobc cases , the pas tends to
iloat the gut up to the diaphragm, and the position tends to pre^e^t tlio
om\ ard passage of the gas It is possible that pitrcsbin might bo of help m this
condition an important one liecaiiMJ of the sj-mptoins produced, the gastnc
deformitj it produces and the waj m ubicli it maj simuhto at times free gas
under the right dome
ANOMALIES OF ROTATION
Tlic most severe degree of fsihire on the part of the embryonic intestinal
rotation is known as —
Situs Imersus Partialis Commune Mesentcrium — In this congenital nana
tion the small intestine occupies the right ahdomcn and the colon the left
Both hn\c a common mesenterj, and the colon is nery mobile The h\er,
spleen pancreas and stomach are normal The duodenum instead of curving
round to the duodeno jejunal flexure makes a looji to the right and joins the
jejunum on the right side below the lucr The ilcura lies below the jejunum,
m the right ihac fossa The terminal ileum runs across the midbne to join the
etecum , the ilco ccecal junction is on the right caical wall The variable
portion of the colon m tlicso cases is from c'cciim to splenic flexure A usual
arrangement is that the cTcum lies near the left iliac fossa anterior to the ihac
colon the ascending colon runs upwards and bends over into a looped or
folded trans\crsc colon It is as though the right half of the colon has
liocn displaced concertina wise towards the left half, and lies more or less
m front of it
This amngement maj ho made out both by a birmm meal and enema
Cases of congenital abnormality of this type arc said to he more liable to the
formation of obstructuc bands and kinks than normal imbnduals
EsinPvoLooi —Tins abnormality is the result of a failure of the nonnnl
rotation of the pit dtinng early iiitrn uterine life (1 ig 182) During the first
fi\e weeks of life, the mid pit, supported by the supenor mesenteric artery,
herniates through the umbilicus into the corri At the ‘ apex of the loop of
herniated pit are attached tiie nlclbne artery and duct (the site of AIcckel s
<h\crticiiliim) rheso divide the gut into pro and post arterial parts
AtAtattxu' Jifvtlmpnt Jvgun.sjdmid Jtlie .tenth .wmk
At first the jire artcnal segment (small mtestme) hes to the nght and the
jjost nrtenal to the left Rotation occurs with the gradual return of the pit
into the abdominal ca^lt^ The pre nrtenal sepnent leads and as it returns
It passes under the superior mcbcnteric arten and pashes that part of the post
nrteri vl or colonic segment w Inch was not hermated to the left there to fonn
the left half of the colon
The caecum i» the last to bo rcturncil \t first it hes in the midluio anterior
to the small mtestme As the lrans\ei«i colon deselops the cajcum traaels
first to the nglit Jiajiochondniim and then down to the nght ihac fo«sa It
244
ALlMnNTARY TRACT
ma) bait m the former iKwilion, and represent the aanation know-n as the
iindeiceiiied cacum
In the ahnormahtj under di«cxis?»ion, the small inte<itme fnil<5 to pass under
the su{»enor me«entcric artery, but remains in the nglit abdomen Tliere u
thus no duodenal loop Similarly, the creiun fads to perform its semicircular
tour to tlie right ihac fo'tsa, nnd remains either in the midline, or ]u>t to the
left as aboic described (Fig 183)
Minor Abnormalities of Rotation — Tlie minor faihires result in the w«
descended cavum This maj be snbbepatic — a rare site — \>ut the cteemn uiote
coiiimonK descends to a point where its ajicx is at tlie iliac crest in the prone
ictvs MtTUtS CO*OTVMi ntUNU'iUn
>10 1*2 — Dissrem illu tratma «!«* tl«eloi>roent of il»c normal gut arul thefrul ui mtiw u»TrtM
{wsition and in the upper part of the nglit iliac fo«aa when erect It has no
clmical significance Xot ou uncommon nimormalitj is the iiptiinied c'ccum
Two news obtain as to the aitiologi of this ectopia (1) congenital; and
(2) adhesions Doubtless Ixitb occur
Kantor dcscrjlx*s a condition of hypadescenl, in which the creum is m the
pthns in the alfeiiee of tiveroplans He states that a clinical sjmdronic i'<
commoiih met with in association with it . refiex loniituig toxic hc'uHfhr'
ami dragging pam in the nght iliac fossa , and that the appendix ts frequently
rcmoicd in the**© cases through a mistaken diagnosis of chronic appendicitis
Transposition of the Abdominal Viscera — It may be important to recogn^
this interotmg tongcmtal variation if an abdominal operation w contomplited
It ma\ or may not Iw aciomiianied bj transposition of the thoracic Tiacera
It Ls of course, \er\ casiK recogm>cd on screen examination, hut in a radio
gram onh if the right and left sides of the film hive lieen marked As this is
Hot iistiilly done in baniim meal examinations, a particular record should lic
imde w lien the ahuotmaltU is noted on fl«ciro»copj
ALIMENTAUl TR4CT
24 G
ANOMALIES OF FIXATION
The colon tends to be relatively fixed in hypersthenic individuflls a
happy state of affairs in them since it is the other extreme that is associated
with sj mptoins Coloptosis is bound up \nth the subject of Gleinrd s disease
each of which must bo clearly differentiated from tbe other
VISCEROPTOSIS
{Syn cnteroptosis splanchnoptosis GIcnard s disease)
O/eiKinf in 1886 first descnlwl tlm condition as a clinical entity It is in
essence a sy mptom group associateil with laxity of tJie pentoneal and iiiescii
tent attaclnnents so that the stomach the intestines tho kidneys tlie Iner
and spleen prolapse to a loner le\cl than that nliich they normally occupy
The organs most commonly affected are the stomach colon and right kidney
Radiography has shoira that there ate three groups of cases in winch the
tvbdommal organs are low m position and it is important to differentiate
between them
(n) Normal Indniduals of a HypostheoJe Habitus — V loar position of the
aisceia is normal m tlicsc subjects and is not meoiiBistcnt with jierfecl hcallb
and Mgorous atlilctic pursuits
(h) Cases in which True Ptosis is present, dependent on relaxation of the
abdominal wall from repealed pregnancies or other cause rrequentlv «n
extreme dcgivc of prolapse may exist without syrmptoms
(c) True Glenard s Disease —Those oases occur m patients of IiyTiostlicnic
habitus and are especially associated with tho neuroses Such patients are
UHualU thin and lacking in abdominal fat and any factor wbicli tends to impair
their general health is apt to precipitate the development of the symptom
ooiiiplox An essential feature of the disease is tlic sy mptomatolop In
addition to the general neurasthenic symptoms there are present those
referable to the prolapsed orgaas Prominent among these are a sense oi
weight and drugging m the abdomen aggraaated by exercise and rclie\e<l b}
hingdowTi and ht mptoms of nervous d\8j»cpsia siith as fullness flatulence
cpigRstnc discomfort and na«sta after eating and Bometimcs actual pvm
( onstip ition IS the rule and there mav be an associated mucous c-olitis
It js idojous Hwireftirr tluxt /hr* \ ray t-viJcncc of abdominal ptosis
n quires the lorroboration of the clinical picture lieforo true Glenard s di«case
can be diagnosed and cv cn if the \ ray signs arc present it is unwi«c to stn^
them to the patiint of neurastheme tv |>c lest symptoms referable to them b.
tonjured up and pcrjietu ited Manv authonties hold the vnew that the droppe
position of tho V iscera is not the cause of the sy mptoins but that it is mere
nn incident in tlic general condition hven m) the radiographic appcnrtinees
give an mdirntion of its existence and h\ excluding the presence of am more
Hcnous organic lesion help m amv ing at tlic correct diagnosis
\XAT05IICAL ^AKIATIO^S OF THE COLO^
247
Radiological Features — ^Thero are certun landmarks in this respect ulacli
nro of help in difrerentiatiiig between the normal hyposthenic position and
true ptosis
Stomach — Xlus organ if hypotonic ma\ simulate ptosis from the sagging
of the greater curve The position of its loner pole vanes greatly m diiTerent
indtvnduaU and at o from day to dav m the same subject This variation i*
due to 1 ary mg tone and has nothing to do nith the peritoneal attachments of
the btomach In tniogastroptobis the descent is due to stretching or increasing
h\itv of the gastro hepatic omentum mid is indicated bv the position of the
le&scr curve and pylonis If thcincisuraangulans is bclon the intercnstal lino
lU the erect posture the stomach may be said to be ptosed
lifL DcroDFVTjr other than the bulb may take no part in this dropping i
in which ca«o the bulb is frequently narrow and elongated More commonly
the whole loop together wnth the head of the pancreas is prolapsed
Thf Small Istlstisl is normally so variable m i>osition that it presents
no satisfactory critcnoii of ptosis
The Coion is more frequently displaced downwards than any other viscus
The transverse colon is so often m tlio form of a dependent loop that no
ajgniJlcanco nttuhes to it The position of the splenic ilctiiro la much tho
safest criterion of coloptosis J»orraaIly this is fairU constant m site m tho
loft diaphragmatic cupola and its descent towards the ihac crest is always
an index of ptoMs The right half of tho colon is so variable in position
that only gross displacement downwards is of importance Another
chamctenstio feature of coloptosis is the tendency of the colon to become
slightly (-Towded tov^artU the midiinc like a concertina The transverse
colon assumes an undulating shape and the flexures are not so far apart as
in the normal
The Ctcum may show a marked mobility and considerable vonation in
position m the erect and supine postures Tins variation or sliift on ehange
from the erect to the supine jjosture is much greater than in tlie norma!
hatitor regards n shift of more than 3 inches on the right side as an indication
of what he calls hypofixation An nntero postenor radiogram taken with
tho patient lyang on lus left side (the central ray licing liorizontal) wall demon
slrate the cmcal mobility m the form of o displacement towards the midlinc
This is however rarely necessary radioscopic palpation in the supine
po«5ition IS nearly always siiflicient to demonstrate the degree of lateral canial
mobility
Thf I IV FR when It descends m visceroptosis tends to rotate forwards and
casts a larger shadow from above downwartls This has it« clinical c-ounterpart
in mcreaso of the Jiver dulliiess downwards and is liable to be mistaken for
enlaigomcnt of the organ
Till NpLFFN docs not cni»t a very definc<l shadow hut bulBciont can UMinlh
lie made out to detect nnv marked ptosis of it
248
ALniENTAHV TRACT
ANOMALIES OF SIZE
Congentlal Dilatation of the Colon (^n Megacolon Hit^cJisprungs disease)
— ^Thia condition is characterised Ly a varying degree of dilatation and hvpcr
troph\ of the colon Mitlioiit an\ causal organic obstruction and obstinate
constipation dating from birth Tlie more severe cases arc met nith in joiing
children lesser degrees of dilatation often tuiaive to adult lift
JIoRBiD Anato^i\ —The dilatation may involve the whole or part of the
colon 'When onl^ part is involved the dilatation evtends for a varying
distance up the colon The caicum ih the portion which most comnionlj
escapes The rectum la not involvetl nor is the small intestine
In addition to the dilatation the colon is elongated This la apparent
particularlj in the sigmoid the segment most constantly atficted Ifrja
aiQinoid when marked results m the eigmoid loop extending far up into the
abdomen not uncommonly into the left hyT>ocbondnum The bowel wall abo
shows muscular hypertrophv and in long standing cases fibrous liyperplaiia
Tlic obstinate stasis that occurs in this condition may lead to stercoral
ulceration
iEnoLOOi — The pathogonesi'j of the condition was tpute obscure until
IlnrH pointed out its similarity to tcsophagcctnsia m cardiospasm and mchidcd
It m the list of disorders resulting from derangement of the sympathetic
neuromuscular mechanism The writer recently saw a case in a Iwy of t
associated with gross double hvdroneplirosw hydro ureter and vesical dilata
tion Further proof of the truth of Ilurata theory is given by the successful
results— sometimes dramatic — of obdominal sympathectomy m those cases an
operation which has greatly nnproved the prognosis of Ilirachspning s di-ea'C
Clivtcal Fr vrrnf s — ^Tlie more markeil en'^es are usually recognised during
the first y car of life These frequently succiioib at an early ago from toxfcnaia
or jierforation Tlie milder degrees nmv escape recognition till later childhood
or early adult life Tlie usual symptom is obstinate constipation datins frt ni
hirthj and gradually increasing abdominal distension Tvanpamtes is
common ami if ulceration has occurred diflirlicea may alternate with the
constipation Scvbala nearl> always fonii in the dilated gut and it is u<iuoUv
ver\ difficult to empty the colon complcfclv either bv purgatives or encmata
Tlie child <!!mws. general signs of chronic toxaimin and the general nutrition w
dofeotivc contrasting with the large abdomen
Radioiooical Fiati ns — Because of the gaseous distension of the colon
tliat IS usually present a plain radiOofam often demonstmtes the dilatc<l coils
clearly but does not show enough detail to diflercnliate a moderate degree o
HirstlLspmngs disease from obstructive coloiuc dilatation
The 1 anum meal should never be u cd in the investigation of these ca«efl
tweause of the difficulty of getting nd of the inspissated banum If d
an obstinate stasis is evident together with marked colonic dilatation Tic
AKATOiIIC\L VARIATIONS 01 THE COLON
24
Inrtuni occupies onl> a portion of the lumen m nnj segment surrounded b
considerable collections of gas
The banum enema is the method of choice In the milder degrco-j c
congenital dilatation it is po'^sible and not injurious to fill the uhole colon aii'
m those cases irherc the dilatation although gross is limited to the lower par
of the colon it is also permissible In marked cases inv olving the w hole c
the large gut it is neither possible nor desirable The capacitj of the colo:
niaj then be an\ thing from o to 10 pints or more It is the wnter s practic
not to introduce more than 4 pints ahd to rel> on gaseous contents to oiitlin
the upper portion Changes of posture e g prone and right lateral ma\ an
in filling the upper colon
The appearances arc tj^iical m a marked ca«e The enema fills the rectun
out to its normal 8 ] 2 e and when the sigmoid is outlined it is seen to benpproxi
mately equal m calibre to the rectum Haustrations are either absent or a er
slight Tlio sigmoid loop maj be aerj long and in the form of an acute
with the hend in the upper abdomen After tl e sigmoid has been filled some
of the barium passes into the colon abo\e but usually gaseous contents therein
pro\cnt complete filling It is rare for the barium to reacli farther than the
splenic flexure in those ad%ancod cases
In the less marked cases the whole colon can usual)) lio shonti bj a barium
enema and m addition to the dilatation the haustra are wide and rather shallow
{Iig 184)
Two forms of aoUulus are apt to (nko place in megacolon (o) vohulus of
tlio sigmoid and (6) «ccondary aolvtihis of the stonincli cither along its long
or its transserso axis Both are desenbed elsewhere
Ruiiooiunnc ArpEACASCLs Arrrn &vmpatiifctom\ — ^Three operations
are «t present m vogue (1) removal of the 2nd 3rd and 4th lumbar scraps
tbetic ganglia on both sides with the connecting rami (2) rejection
of the niesiallj directed branches of these ganglia onlj {Telford and Slopford)
and (3) penartcrial sampathcctomj bj stripping off the plexus Burroundmg
the first incli of the infcnor nicscntcnc nrterj In the latter operation the
ascending branch from the sacral autonomic plexus wluch joins the arterial
plexus must not bo cut If it is the operation will fail to impro\c the
conuU'ion
Of these operations the last is if anj'thing more in favour at the time
of writing but satisfactor) results are obtomed bj all and also failures
The radiographic appeirances after operation are variable In some
suct'e'^fiil cas-es there is a markwl diminution in the colonic calibre
(Fig IM)
In others there IS no apprcoiablo diminution when filled b\ abaniim enema
m spite of an excellent physiological neaalt Persistence of the dilatation after
operation therefore docs not indicate that the operation has licen unsucccssfu!
In tlic*>e a I anum meal gi\es a truer picture of the real state of affairs
250
AI.ntENTARY IR ACT
Otiicr operations which are performed on occasion arc colectomj, complete
or partial, and ilco sigmoidostomj'' {Fig 185)
Caliac Disease (^yji Gee a du.ea'^, Bcrtera disease, idiopathic steator
rhcca)
This IS a chronic disorder of nutrition, characten‘.cd h^ wasting,
abdominal distension and frequent pallid stools The essential feature is an
W ffe)
Pio 1S4 Hirschsprung 8 (li«i'a.*e (a) ©I ^rolion (6) 18 moi after « im“«rul
»\tnpat> ectoinv showine morkol diminution m the catit re of the colon
intolerance of fats and carbohydrates m the diet Tlie cause is iinccrtam
The intestinnl mucosa may be atrophic and the small and large intestines
(partituhrly the latter) dil ited flic condition is usually met with in children
lietwcen 1 and 5 \ear8 of age It nl&o occurs in adults
Radiological Features
Imasts — It Otibcrl and L Jiabatantz lm\c imestigated the rmiiolopc®!
apjicarnrK-ps in infants and ha\c di scribed changes both in the motility of >e
small inte»tmc and m the calibre of the colon Tho transit of a meal throug »
the small intestine ina\ lie unduly rapid m early ca«cs but m the later
It IS iisualh delayed riiesc wnters also noted an irregulantv in the rate o ‘
III the annil and large intestines \t one time jejuna! and deal tnin''it ina' >e
AN ATOMICAL VARIATIONS OF THE COI ON
2ol
npid anti at another stasis maj occtir Similarh the colonic activits maj
sary between stasis and frequent but tmj e\acuations
Roth the hrge ami small intestines are usually dilated parficularlt the
latter This mnj bo demonstrated by a liarmni meal and m the case of the
colon bj a barium
enema Tliere is a ten
dency to irregular fleck
mg of the small intestine
the barium Ix-ing distn
buto<} m i^eparate dts
tended cods wath gaps
betwten The colomc
shadow when seen by a
barium meal ma\ bo
mottled from mixture of
translucent and opiqiic
contents
AntLT$ — According,
to d M Snell and / D
Camj the small intestine
shows definite radio
logical changes when in
scstigatcd by a barium
meal In three ca-^cs
which they report tran
sit tlirongii tfie jejunum
was delated and the
normal feathers mark
mgs m the gut were
absent In place of the
latter the banum was
dispo od in aggregated
elongated- masses along
the jcjtmtfm Those
writers attribute this
tio tb$ — Cotectooj an I «lr« « i^no ttKtomj for H rwh
»Snini,B •( praranc " ho in* afi^r n banuni incol
Xo<o tie t fated itcum
appearance to the presence of inflimmatorv changes m the mucosa and sub
mueo a and to the abolition of the normal actuity of tl o muscularis mueosT
T I ofl iJcnntll D //inter and J M lauglan ba\e de«cnl>ed fifteen
eases in adolescents and adults The clinical features m the e eases were
flt^^ stools witborwithoutdiarrhroa tctan\ anamia skmlesions infintihsm
osteomalacia and colomc dilatation In eight cn cs examined with a banum
inenm six sliowed colomc ililatation aarymg from a mnflpmin nior.*
the desrenilmg portion to an extreme nic^aeolon
ALDILKTARY TRACT
Th E Ileti Thayson found colome dilatation in four out of five mlult
cases examined and noted that this dilatation began in the sigmoid and gradu
allj extended upwatxls
Irancom Ims stated that if the colon is thoroughly emptied by lavage it
tom|)orarih assumes a normal calibre
There remain to be described some of the rarer gross congenital defccto
nhicli arc often incompatible mth life Among-jt these are absence of entire
colon or part tliereof double barrelled colon , and micro colon
Absence of Colon — The entire colon rectum and anus may fail to deieloj
but more commonly only a jiortion is involved The CTCum ma\ be absent
and the ileum pass directly into the ascending colon viathout the usual
sphincter or the right colon may he absent and the ileuin be joined to the
transiersc colon
If a largo part of the colon is absent an umbilical frecal fUtuIa ma\ be
present — via a patent Meckel a diverticulum
Double-barrelled Colon —This h extremely rare Locheood lias rejmrfcd a
case of a descending colon with a double lumen each patent at both enU
One lumen the larger perfonncil the colomc function
Micro colon — ^This too is a taro congenital abnoTmahty which is usually
incompatible w ith life It may bo partial or total Fyje and Lardcnnoit have
each reported a case of total congenital micro colon the lumen lieing narrowed
to a few millimetres
D M Gmg has made an exhaustive study of four cases and points out
that the colon may also ho ectopic (e g the CTcum near the site of the normal
hplonic flexure) and il o that the lower ileum may be considerablv dOated
F B SlepJcnson aho rccorils two caws Both showed incomplete
rotation of the colon In one tlio c'ccuw was subbepatic, in the other suh
splenic In the latter the ileum was grossly dilatcil and the colonic lumen
was o mm in dmmeter Iho rectum was aKo indistensihlo Both cases die*!
shortly afterbirth
ANOMALIES DUE TO ADHESIONS AND HERMA;
Peritoneal Adhesions involving the Colon
rcntoneal adhesions between adjacent rniN of intestine and between (liem
and the panetes arc verv common much more so than would ai’pear Trom
\ rav examination
The great majoritv of adhesions ore syinptomless and giro no radiogrftpbm
sign of their exislence A small percentage give nse to symptoms but are
undemonstrable and a still smaller percentage cause sv mptoms and can al«*>
shown nwhologically
The \ my dcmonstmtion of adlicsions of the colon depends on three elTccts
of tl 0 adhesion fixation of the adherent viscus , def< nnityr of its contours ,
A^ATO’i[IGVL ^ARrATrO^S OF THE COLON 2o3
and obstruction to the onward passage of its contents At the same time the
mucous pattern of the colon should remain intact (Figs 18G-18")
Fixation of the colon b\ adhesions can be demonstrated onlj if the viscus is
nonnalh mobile and if it is accessible to radioscopic manipulation The
cajcum fulfils both the«c conditions and fixation of this % iscas is a reasonabh
strong indication of porica?cnf adhesions This const itiites one of the access oia
signs of appendicular di case The ascending colon liepatic flexure and proxi
mal two thirds of the transxerse colon are similarh accessible to tl e pilpatmg
hands an 1 are usualh mobile but tl e hepatic ficKiire ma^ lia\e no mesocolon
A A
i t
Fia ISO — an of* ano lob^in ct on na|»»l ontMtsI 8 Tl Dophtntfn*t to boneort no na,
I on pt\ 1 1 of 11 <• tl onum entma »! o»cJ a normal mucous pattern an I nrt cntwl a s mple
liM on \t ojwrat on oL truct a 11 p» ns wero foun I
uul so lm\o little mobilitx while hxpertomc abdominal muscles maj pre\ent
free manipulation of the transxerse colon Tlic splenic flexure is far out of
reach of the palpating hand unless it is ptosed and adl esions m this region
eg from perisplenitis cannot lie detected radioIogicalK unless tlie^ cau.ee
obstruction The descending and iliac portions can again be palpated satis
fnetonh but the pch le loop is frequently | lace<I too deeph in the i>eh ic basin
for tins piirpaee
Tff dffonnatton of contour nm t typical of a iliesions is an nl nipt anguli
tion fins angulation must be a real one tluit is it must be distinguished
from a roundctl Iwn I m the gut xicwcd cn 1 on Such an angulation is usually
ALniEXTARY TRACT
2 '>4
necompanied bj some narro\\ing or compression of the colonic lumen, iihitb
if marked, produces the third fcign» obatruclion of the lumen It should bo noted
that an adhesi\e obstruction of necessity shows fiiation also, and probable
deforniitj or angulation It 13 cttremely unhkcl} that an obstructed colon
w Inch IS mobile at the point of obstruction is due to an adhesion band
Adliesions ’ is a diagnosis to be shunned e\cept on clear CMdencc It is
a non committal diagnosis one that nowadays seldom leads to opemtive
(ol
Fjo 187 — A cn-v(f a II mionsfrnttKAlruIoiu | onnrplintw (a) Filijni; jlpfect *n ^
colon w til A luiniiti) cnemo nimtilatinfc •• carcinoma (6) \ftcr air inflation mucous pa
"li >wii e 111 the iffen >m ?<1 nf^mcnt
inlcrrtnnce except in \erj dchnitc olistructire eases, and one that
cnsil} to t lie |)en of tho^e expected to sohethe mister^ of thejiatient’ssvmp
toms b\ \ nia exnmiiialioii It is still a regrettably common diagna«i‘i on
slender CMdcncc and more lointiionly wrong than right
Herniation of the Colon — ^TIic «plenic flexure is not nncommonlv
in a left diaphragmatic hernia and always in Petit s cxcntmtion The trans
aerse colon max occupy a rcntral or umbilical hernia and the cscxim au'
fcigmoid lie p^c^ent in the inguinal and femoral xaricties
CHAPTER XXI
LAiDIATORY DISEASES OF THE COLON
SIMPLE COLITIS
CoTrn*^ IS a term applied to manj \aned conditions, from the fco called
irntahle spastic colon to the graver forms of ulcerati\e colitis Ob\iously tho
radiological picture must varj ntconhng to the type that is present Tho
radiological separation of the aanotis t^iics lias lieen ai^sistcd hj the adoption
of the thorium three stage enema
Irritable Colon : Colospasm
The Simplest tjpe is thercne< ncuro muscular and \nscular disturbance
dcficnlied bj J/wjwjo/ as the (M tmUtUj and cornmonl} tcrnierl in this country
colovpasm ortho ‘ imtablo ” colon The adjectne “ imtable,” thus loo«el>
u«od, 1 " meant to indicate a state of nflairs in «)uch the colon tends to a state
of muscular hJ^)crtonus and hj-pemctuity of theimusculans mucos® It la
said to result from nian^ mtnasic and extnnsic abdominal Jesions, and also
from numerous remote constitutional disturbances JIainffot has compiled a
forniJtlable list of causatiie factors Amongst tho general factors he groups
ncraous, cndocntic, and allergic disturbances, leukemia, drugs, such as pilo'
carpme ami purges, and general toxic states
Amongst abdominal causati\c factors, he includes almost anj le«ion that
can occur in tlie ahdomen
Rsdioouapiiic Fi-vTcrls — Tht barium enema show-s n relatixeli hj^ier*
tonic small bored colon with fine hsustral contractions This is pirticularly
so m the left half of tlie colon, and in tliosc cases which are so commonly
laWlled colospasm on radiographic examination the enema may lie completeU
arrested bj a temporarj spasm of quite a long segment of the iliac or descending
portion of the colon After a httJc this usually relaxes enough to allow the
upward passage of the medium
The ihonum triple method gives chamctcnstic signs by which this eolome
s\ nilrome or reaction muv be recogni-»c<l The mucosal pattern after emptj mg
oliows the pile® to be smaller and more numerous In addition to the nonnal
transverse pheas there are added secondary arbonsations which make a close-
pet and complicated pattern
This change is suppo-ed to 1>c the result of stimtilation and increased
nttivitv of the miKCiiIans mucosas Pan passu with this some increased
vasculantj may be pre^-eiit. Tins causes thickening of the plir®, and repre-
pents the po called flat cTvdatif,
250
ALTMEXT\nY TIUCT
■Most coinmonh a nii’ced reaction t'lkes place and mth the secretion of
c\ccss of mucus the picture is that of simple mucous colitis
Mucous Colitis
Tilt mdiogrophic features of mucous colitis are slight and inconstant or
nb«ent altogether in a barium meal or enema evamination but u ith a tlionum
■ur or banum nir enema more definite change maj be dttccted
II ith the barunn meal coiistiiation and formation of scibih are common
concomitants but the\ are not essential parts of the rithological sjuidrome
rather aie tliei cominonlj associated states A not infrequent appearance is
the change knoim as Cranes string
fiign This lb a streal or snail track of
barium hid down m the lumen of the
empt^ colon m the trail of a mass move
ment It is a variable and unreliable «ig7i
since it inaj bo present not only m this
condition but also m deaelojicil uiccntisc
coUtLs ami m the normaUubjcct Itniai
extend oier n foot or more of tlio colon
and IS most eummonlv seen m the desccnil
ing jiortjon
Uiffc the barium enema uauiUj no
changes are apparent imless there !«
some hjpcrtonicitj of the mn«cular co da
again espccialh on tlio left side and some
fine Jiaustmtion In borne cases ndhomit
mudis causes fine irregularities in tie
barium filled contour of the gut llie c
disapi>ear after thorough prejviration a
point which distinguislies the condition
from ulcerative colitis in which tiio
irregularities arc persistent
The rtonwrn-nif enema sliowa a sinulir
apiKjamnee m the first stage that of
filling The collnp'^cd lumen t^picall^ ehowb increase in number and thicken
mg of the plica h ith -i fendencj to formation of opaque blobs at points |Fjg
1S!») After distension watli air tlicsc thorium coated drops of mucus can le
seen ndhernv to the Inuco^a en fare and in profile A Biiuilnr appeamnee
iiia\ be with the barium nir enema after inflation
ULCERATIVE COLITIS
iEtiology — LIceratne cohtLS max result from a xanetj of causes such ns
(I) Siicrric iNitCTioNs among the principal of which nrcamcche am
I\IIA^nLV10R\ DISFASPS OF THE COLON
2o7
baciHan djscnten the tj phoul pnraU'pljoul group lambba tuberculosis
and S3'philis
(2) CoNsTiTiTrONAi, secoiulatj to Bright a disease gout or pliimbisni
(3) STERCOnAi, Ulclrvtion especially abo\c a stneture
(4) \ vscLi*AP following ^ascular disturbances sucli as portal obstruction
or mesenteric embolus
(6) Paraplegic
W ith the exception
ot the tuberculous ami
SATihiUtie groups the
specific forms of ulcera
ti\c colitis tend to
become seconilarilj
infected and to merge
into the n m specific
t\j>c
I he Inctenologj of
the non specific t\pc is
obscure The moat
serious and acute cases
are slid to be the re
suit of streptococcal or
pncumococc \I infection
but usuallj a Aanet\
of organisms is pref>cnt
Pathology — Three
stages m ij 1x3 reexjg
nt'>cd in the condition
the stage of on'-et the
do\cloi)cd stage and
tfie stage of ndcnncod
fibrosis The three
t-tages show dilftrcnt
rvU vlogical features depcwlui^ on the pathological cUauge^
In tic Jirfit ftlage tlic mucos'i is siiollcii and congested ami the buhnnico a
hliows hmidiocitic infiltration Miliari submucous nl socsscs develop W I en
t! e^o break dow-n tins ulcers form bnd na tl csi, incm«e in sire //c Aeco li kUijp
IS rc i< lied 1 he submucous cost Ik tomes tl ickencd and n detn itous and the
hmilKcvtic infiltration iiicri ws leading to minute li mu rrliages Ihe
ulcer margins 111 l>econie inuU rmiiit d andirnnal re^s tlevclcps lietwcen tin
imi cular coats a colfsr stud cxviti or fa! c tin erticuluin nia\ occur
n i ulcers tl n 1 to devclc i> in the li lustral saeeulati >ns In mdesj rend eon
tluent ulceration the nniuns cf tin iniiro i i
\ R ir— 17
I nl of a I a
. itli pol.spuiil formifti
SCO ALIMENTARY TR\CT
j>ro(luce a nakednjje npj)eirance like a honejcomb An important feature of
tins stage, from tlie radiological point of mc", is the relatire loss of chsticitj
of tlie boVel Mall, tlic result of infiltration of the suhmiicosa and musculans
Jlcslilutio ad integrum can take place onU if cure is achic\cd in the earl^
stages In later stages licidmg lakes place, if at all, with fibrosis In chronic
late cases there is often a mixture of mucosal gramilomatous nodular or polv
IKudnl formation, Mith Hubniucous and muscular fibrosis and scarring Both
of these are radiologicallv important
Sooner or later in adtmiced cases, cicatricial contnicturc causes localised
stricture or general contracture of the bond and if a cTcostoinj ins been
performed tlic colonic lumen ma\ liccomc completely obliterated This hat
occurrence is demonstrated b^ the failure to introduce a thin Innum cream or
thorium susiHJimon along the colon b^ cither the stoma or the rectiiin
Radiographic Features
Sxvot oi OwFT — ^Ihe ulceration usu»ll> liogins m the sigmoid and it is
tliLic that the firht changes are \isiblc
Mlien filled Mith a Innum enema the afTcctcd segment mn\ show gome
h\|>crtomcitj and its contour ma\ lie lather shaggv
Hie same appearance is seen in the first stage of ft tlioriuni enema The
mucosil iialtcni m the second stage that of collapse, is chnraetenstic The
plication of the mu< osa is cumplotcl> disorilercd There is no s\mnietri in the
plitaj tthich take the form of an irregular enlarged and mottled network
Las mflatuin proies the colonic Mali to bo normally distensible The opaqwe
contour line is intcrnipted and inegular and tmj nicer crateia. maj be defect
able on occasion Ihe mucosal surfaic hcen eji face maj present irrcguhr
opicpic droplets of till uim(|iie medium
DiMLniiD Staol — As tlic jiroccss dcselops the railiological picture
changes llie ulcers arc larger and tend to be confluent their margins under
mined and the affected portion of the moH infiltrated ind thickened
The barium enema method liegins to reveal charactcnstie signs On
cd»sor\mj; fluoioseopicallv the enema running m the impression is gamed of a
rigid contractcil tulw Ilaiistration is feeble or absent iml tlic transit of t ic
( ncma through the cxilon aer\ rapid The ah«.cnce of haustratiou prwhiew l 'C
Mcll kiioMii nbhon sign (Tig -Ihe colon appears as a bihooIIi ^
filndoM often if cicatrices hue not developed remarkabh uniform 1 “*
apI»carinc-o is due to the ngidit> resulting from tho infiltration of the fiC
nm''mis nml mustulai coats An ulcti crater pcch m {irofile cau'C^ i”
imguliritv on this smooth outline if its edges arc iindennmtd iiotciicsiiii'
<•1*011 The undermuitd imicosu maj usult m a double contour in
sections <)1 till loloiito profile . ,
Uitli tbc tlioniim tuema the ^la/e nfjtlhng shous an ajipcarnncc <•
saim t\jH ns nlKiM but the degree if filling all >ms iiion irn,.idaritv •
UsFLVAIMAlORY I>IS1-ASFS OF THE COLON
2G1
tlic contour to apjte'tr to « Inch underminctl enters Ii\peTtomtit\ infiltration,
011(1 fibrosis nmj all contribute FhInc diverticula maj be present and be
\jsible The sta/jt of coUajiK is marked bv a failure to collapse co'mpletel^
Tlie boMel \iall has lost its ehsticita and the lumen is not emptied sufllcientl}
to dccelop a satisfactory mucous pattern In tbohe segments winch do empty
themseUcs the plic-e arc scanty and ill dc\clopcd The stage of inflation
prows that tlie ngidity of the colonic wall is relntue — the lumen is larger than
m the first stage The contour here is
yery iiregiihr and broken bj spiky
projections and, maclie fal e dner
ticuh The intcrmargiml zone shows
coarse irrCoUlar reticulum
Ihr>RrL.\sTic AND Sci moTic
‘sTAoi —The barium enema shoics \cr\
typical changes flic rigid tube and
ribbon shadows jiersist and tliere is a
consuUnble dnmmilion of the colome
lumen Irregular stono«ed segments
arc clearly yisible and luuistntioii is
completely nb'S?nt ff in addition to
the hv^ierplnstic filtrosis the mucosa
dey clops jioly ;xiid grn n ti t o mat oils
ilmiigts thc>o will add a further
irrepilnrity to the contour
Ihefillodstagoofthcthonumcneimi
shows a similar upi>enrance Collni>^
of tl c colon hareiy takes place and no
hiucontI phcjc can be iisuahsed In
nation causes shglit dilitatioii of the
less afTcctcd jKUtions of the gut but is
unable to distend the stenosed scleroseil jiortions Ihe mucosal pattern enface
IS a disorganised reticulum in which ulcer crater or diverticiiJiim mai make
Itself \isible
tl 193 —D voloftsl uleernt VP rol In
will al«!<«Tirc on A wlrnt orn nn I rillon
COLITIS DUE TO SPECIFIC INFECTIONS
riiosc forms of iilcemtivo colitis resulting from infection with the ent imceba
liistolytiia lambhn tncliomonas or the dysenteric bacillus show no radio
logical fentuivs to distinguish them one from another cr from the non specific
forms ilescnlnd aboae
The diagnosis rests securely on the results of bacteriological cvnmination
and this establi hed radiograjihic examination hcr\c« to indicate the degree
of the iwithological changes llie earliest 8 tage«, show the apjtearances of a
iimc(m<i colitis the later those of an iileeratice cxilitis m its aanous stages
202
ALfAirNTARY TRACTl
0
to tho contracted filirotie stage It is baicl that if the nmcnbic form
l)cconios clironic it shoAis in its lafe stages an especial temlene\ to fibrotic
contracture of the gut
SYPHILITIC COLITIS
Tins condition is extremely rare and exhibits a preference for the sigmoid
and rectum
Tho essential legions are gramilomntous formations and ulcemtion In
general specific sigmoiditis mn\ take one of t«o t>pcs— m inhJtrated nncti
tio IJI roUi>oi(l uWrit cotiti.4 Blourinjr lonojootnl pattern four hnur« after a n cal
in w hicli tho submiicos \ is permciteil and the eignioid transformed into a rigul
tulie and i In pertroiiluc xarietj in nhich the nail of the gut is greatlj
thickened and nodular and the lumen irreguhrU inrroued fhe deciding
diagnostic points arc houeicr not radiological but serological histologicnl
and tlicrijtciiCic
ILEO-CiECAL TUBERCULOSIS
Pathology — Hjpcrplastie tiiberculosH of the bouel affects the cxcum m
tho nmjoritx of cases and mn> spre-ul thence to the ascending colon and the
last inch or tuo of the ileum Tlie fcUiirc of the contlition is the marked
thickening of tlie cajeal uall and consequent inrroumg of its lumen
INTIA'MMATORY DISEASES OF THE COLON
2G3
The <lisca«;e starts in the submucous coat uith a chfTuse round celled
infiltration, folloMed bj a CMji^erable fibrous l\jT)erplasia, both m and round
the wall TJic mesocolon bo intolred and, contraction, drag the
c'ccuin upwards The ilcoctcnl and adjacent mesenteric glands are often
affected Ecentunlh tlio lumen of the bowel bcconies fibrosed and markedly
narrowed, with gradinllj increasing obstruction
In addition to the hjperplasia, ulceration of the mucosa raaj take place,
and poliTioid aegetations maj grow into the lumen
Clinical Features — The disease is most commonly met with in patients
between 20 and 40 \ears of age, and has on insidious on«et There iHa\ or
inaj not be a preceding in\ol\ement of the lungs In the earU stages the
patient ma> eoiuplaiii of little more tJian ragiie ill health, and a hen«e of
discomfort m the right ihae fossa With the onset of ulceration, diarrhaa and
the passage of blood and mucus maj occur As the disease progresses further,
a palpable mass becomes detectable in the right ihac fossa and signs of chronic
ileal obstruction make their appearance
Radiographic Features — Tlicse depend on the stage of the disease In the
carl^ stages, before the onset of olistniction the abnonnal apjieannces result
from the rigiditj and contraction of the caecal walls Sherlm has described a
sign which he belie\ed to bo pathognomonic of ccccal tuberculosis This
consists of a gap in the barium shadow in the cxcum when the ileum, cacum,
and proximal colon arc filled a banum meal At, sn}, six hours after the
iiigestjoii of the nieah the ileum js filled doivTi to the ileo c'tcal \ahc, and also
the ascending colon, the caicum, on the other hand, remaining emptj Although
in some cases this is a pure spastic phenomenon, it is sometimes due to spasm
and OT^nnic contracture eomhmerl The amount of deformity due to each
factor can he detenmned by a barium enema, a method winch delineates the
degree and contour of tlie narrowdl lumen with much greater certamU, and
which should lie used in e\erj case that shows a suspicious appearance with
the banum meal The t^pc of filling defect with a banum enema depends on
the macroscopic form of the disease present \\ hen hj’perplasia predominates,
the narrowing is more regular, and is of the kind seen in scirrhous carcinoma
of the stomach When filled wath the Imniini enema, the cTCum is frequently
conical the apex downwards The margins of this cone ma\ Ixi fairly
smooth or jagged and indented The presence of nodular masses projecting
into the Jiimcn causes irregular " finger pnnt ” deftets in addition to the
hjqicqtlastic narrowing Wlien the jleiim is in\ol\cd the barium meal maj
show an irreguhrl} narrowed portion contrisfing with the nonnalh
filled jwrtion proximal to it Sticrlm’s Bign is not cxelusiic to ileo ca?cal
tiilxirculosis i'lg 1(52 shows a classical Stierlin’s sign m a case of Crohn's
disease
With (he onset of chronic obstruction, the radiogniplnc picture of ileat
stasis IS added to the picture This is shown onK b\ the meal which should
J04
ALlMLXTAn^ nUCT
tlieniort! be as a routine in additinii to tlie enema m tJic in\ estimation
of these cases
Tht wiKfoiM pallerii shown b\ the tlioniim flotculent enema maj show
features of importance in the diapio^te These \nry according to tlie pre
dominant pitliological process in the ca^e
In the ulctr livperphustio form the affected cajcum shows m the collap-ed
stage of the thorium enema albcncc of the pIiCT which ha\e lieen destro%ed
h\ the lisea‘!c or a few scattered and di80fyani«ed phesc separated b\ arei«
Fir 1 J Ti Ijrmila * of tlw cwuin nn I Hisorn lm« colon
( i) S- ten I our< nfier nn opwjgf* n col ^hnv n** ob<lnct ilcol slot < nn»l St cri n a » yn
(h) Tl o Mim M tri bt a 1 an me cma
.Mth no ^ign of phci Inflation of the colon fails to distend the eajcum to an
-\tcnt depending on the ilegreeof infiltration and ri"idit\ of the wall of the giit
IlNperjiKstic nodules ina\ lx; «Kx;n in relief hut ns a rule the distension is in
suflicient to show the e The colon distant from the actual lesion ma> show n
reflex imtatod state of tlie inuoMa as described under the section on cohti«
\ u intreast in number and decrease in size of tbc phex tlieir general imnge
ment remaining intact Tlie ascending colon adjoining the affected cacuiii
ma\ «how a mixture of these states — areas of l^^oKemcnt b\ the sjiecifii
process with adjicent areas of normal but rcflexlv irritated mucasa
In those cx'cs in which the Inperplasix lx*comcs jwl^poid the latter state
IXFL^ADUTORl DISEASES OF THE COLO\
20
adds a tvpicil fe iture to the local Tnuco<^l picture anirrcguIaropaquenetM ork
oHtlimng roundetl clear areas of varying sizes and shapes — the pohqKud massco
In the fibrotic form the conical constriction h more marked iihen filled
«jth the enema In the sta^ of collapse no phcT? are vj-ible hut the colon
ehewhere is «aid not to show reactive change*? DiUtation air is impo^ible
because of the rigid fibrosed ca?cal wall
Differential Diagnosis — ItisobMous from the above that ca?cal tuberculosis
presents a radiographic picture \ er\ similar to carcinoma «o much «o that the%
Fi<' J96 — 3Iullj le tubcmil<wM in tl e colon.
art tus a rule radiologicall^ indistinguishable Culcifietl ileo-c-etal glinda ma^
l>e \isible and suggest tulwrcle as the cau-^ but with no certamt\ emcc the>
im\ reprcsint mereU a juvemlc adenitis long 'since healed and mi^ Imc no
connection with the actue creeal loion If the hanum meal show-s ln^olve
inent of the ilcum al o a tulxTculous lesion is indicatctl
Localised app^i dtr ab^cf-sf or jTftnrfic ^equelrr from an old nbscca.s maj al*o
caiL-ie so sumhr an apjieamnce ns to be imli tinguishable in a banum enema
hut the fhonuni lutthod shows i itormal mucosa which serves to diFercntiitc
260
ALDIENTARY TRACT
them Unfortunatclv the tlionum enema js often iiiisiitce's-sful so far as the
ca?tum IS concerned
As a general rule no confident radiological differtntntion can lie made
lietwcen lieo ca?cal tuberculosis and caranoma, and the safe rule is to regard
the condition ns tlie more senous, unless clinical, serological and bacteriological
c\idence gucs a lead E\en if the condition is mistaken for carcinoma no
great barm is done, since tlic tuberculous lesion is likel> to come e\entualh to
surgical interference
Acltnotjnjcoti3 of tlic ilco csecal region is similarly indistinguishable radio-
logically.
ACTINOMYCOSIS OF THE COLON
This IS a rare disease, and its radiographic appearances are as a rule
indistinguishable from cancer
Querneaii describes a case in\oUmg tlic descending colon, showing with
a barium meal n constriction of the gut similar to tliat of a scirrhous carcinoma
The absence of ulceration of the mucosa was noteworthj in this case
L P Oood reports a ecnos of sixty two cases of abdominal actmomjcosis,
and points out that tlie primarj lesion m "7 per cent of them was the ileo
circal lesion The majorit} start with the signs of acute appendicitis, and after
npj>cndicectom\ o xinits persists and a thickened mass develops m the nght
ilmc fossa from the brawn> Ieathcr> inBItration of the surrounding tissues
The ileum and ciecum arc commonlv involved m tins infiltration Heal stasis
IS prone to result and the contracted, deformed, fixed excuin ma> be seen in a
bnnum enema The filling defect is often indistinguisliablo from carcinoma or
tuhtrele and the diagnosis is mjcological As the cliseaho progresses abscesses
tend to dexelop m the lungs Iner, kidneys and abdominal wall
CHAI>TER \\1I
COLOMC STASIS AND OBSTRUCTION
CONSTIPATION
Constipation or functional stasis m the lai^e intestine is thfficult to define
on account of the marked vanations which occur in normal indi\nduals In
some subjects the normal habit two or three eiacuations per dtcm m the
great majoritj one iicr daj but on the other Imnd one eaacuation e%erj two
or tljree daa s ma^ be consistent mth normal health
Constipation is one of the commonest complaints of neurotic mdividuals
and 13 often complained of even when it does not evist It is a commonplace
tlmt in budi patients who regularly do e themselves with aperients and
purgatives of all kinds the failure to obtain an evacuation on a single daj at
once precipitates an arraj of symptoms such as abdominal discomfort and
distension actual pain nausea las^^itiide dizziness etc In man} of these
cases it Is obvious that the sjTnptoms are part of the neurosis and tint thej
ore produced not bj the constipation but bj the knowledge that the bowels
havonotneted Radiolog} ma> bcofhclpiDthemanagcmcntoftl ese patients
bv demonstrating tliat there is no real stasis in tlie colon that it is controlled
adcquatel} bv simple laxatives or that tlie stasis i» rectal m site and therefore
without lenous constitutional effects
The chief value of radiolog} m the investigation of constipation is in differ
entiating functional sta«is from the organic obstructiv e type Tins la discussed
in the section on organic obstruction of the colon Three tviies of functional con
stipition are described according to tbe site of the delav caieal colic andrectnl
Caecal Stasis — This is rare and is detected only b} nbanum mealexamma
tion The patient is unaware of the condition since dailj evacuation takes
place in the normal wav and it u> doubtful if it lias anv clinical sigmficance
The mam length of the colon empties itself m normal time but the caecum
tends to retain barium Some writers have descnlicd it as one of the signs of
chronic appendicitis hut this relationship is also very doubtful Barclay
suggests tint It results from a defect m the meeliamsm of the mass movement
of the colon He puts forward the v icw that if the point d appui of this pen
staltic wave (m other wonls the initial constncting nng) is incomplete some
of tlte colonic contents arc forced haekwords into the c'ccum and pack it
This appears to be the most reasonable explanation
Colic Constipation — ^This is tl e commonest tvpe of constipation and
re lilts from n failure of the normal mass mo\e"’^"t Tn <inmp rns/'a tlir.
■•6
208
ALniLNTAn\ Tincr
supposcfl (lela\ is pluniulogicnl and rejpres»ciit« the normal colonic habit In
others it i'. pathological and ma> be associated with aanoiis conditions such
as tlio neurones Msceroptosis and mucous cohtis Poisons such as lead
nicotine and the opium group tend to abolish the reflcK and so produce stasis
Vh-^nce of residue m the diet is said to be a factor but if so it is not an
important one m most cases
RADiocRsriiTC F> VTiTiLs— 'Ihe stiaia iiiij take phee anywhere in the
colon iirojicr and is most common m the trinsscrsc portion It is demon
stmted clonrl} h\ a hanum meal but in some cases the stasis ns shown hj the
hantim meal is less than irith ordinary fond The mass of the Innimi in the
colon maj excite a moss moicment in a waa tint the nonnnl contents do note! >
The expeniuents of and f recdlander with glass beads with ind without
a barium meal confirm this slight accelemting clTect of barium sulphate In
the carK stages of the hanum meal examination the contrast mediiiin tuaj be
disixiscd c\cnl\ m the transverw? colon with deep regular Iniistrations but on
siitcccding davs scihala arc formed and the baniim tends to be scattered m
irregular ma-vsis cspetialK m the distal portions This irregular distribution
with intencmrig iKirtions of cnipt\ gut and the absence of am colonic dis
tension are impcrtant indications of the functional nature of the stasis Tii
mild degrees of stasis most of the barium wexaeiiatcd m three da\s In scsere
degrets a week or metre max e!ai»se but it max l>c too uncomfortable for the
jwticnt to prolong the examination to the end in these cases K shorter cxnnii
nation ^ixes the neco<.'arx information and the effieacx of the patient s usual
uiicnent max then lie iiscfultv detenmned
Rectal Constipation (9^11 dxNchosia ordxskcria) — Tlnsisatnmmon xanctx
and rt suits from the loss of the tlefi cation reflex The commonest cau-^ of this
lass is Hewlett I he patient gets into the lial it max l>c in c Iiildhood of ignoniv
the daiU call to atoo! and the reflex pradinllx disappears In addition to or m
plan cjf simple neglect there max lie other causes Ucnkcncd al domitial and
pelvic muscles from rcfieated pregnancies arc Mid to makedef cciition more difh
< lilt andac t ascontnbutorx causes Inflamed piles fiasure m ano andchronicm
flamination aftlicnilnexa make dcficcntion painful nnil tend tomliibit the reflex
RADiooitAniic FtAxmis — The charnctcnstic appearance with a barium
meal IS the collectiou clax bx day of au mcreasmg moss of barium in the
rectum until 111 a marked ca«e the latter is dilated out to the size and sliajH*
seen in a nonnal hanum enema examination If a moderate mass is seen on
screen exnmiinfion at the twentx fourth hour and the patient admits to no
desire to go to stool tlie prenmec of dxa>kc?ia is probable \ larger nia s
present on the following ihi^ confirms it
\Miile fxnstipitjon eon Ik? nicliologicallx exainmed onlv bx tlie*binum
meal it is »t) important not to oxcrlook any organic colonic cause of Ibt stasis
that tlic men! should l^e followed bx a banum enema in exerx en^e 111 x^bicli
fliere la the least doubt
COLO\IC STASIS AND OBSTRUCTTIO^
269
COLONIC OBSTRUCTION
Acute Obstruction of the Colon is too urgent a condition to nllou of nnj
length} rediologicnl iniestigation such as a baniim enema Its presence and
site can houe\er bo showTi in man\ cases bj n plain radiogram of tlie abdo
men This is a feasible procedure m an institution where a mobile ward equip
ment is a^ avlable The colon above the point of obstruction tends to become
distended with gas and so is visible
In favourable cases this distension
extends right do\ni to the obslruc
tion and locates the latter This
docs not alwajs obtain and carc
must be exercised in naming the
exact site Frcquentlj the evidence
has a negati\e rather than a positive
value rims if the c-ecum and
transverse colon are unifonul} dis
tended it can bo said that the
olstniction IS not above tlie splenic
floMirc and a statement oven os
indefinite as tins maj give tlic sur
geon the indication he requires in
planning Ins incision The presence
of fluid levels in the bowel above
the obstruction is often an important
diagnostic feature These inaj be
shovm 111 a lateral neu taken vnth
the patient supine
Chronic Obstruction of the Colon
— Entliologj asariile gives defimto ,, p, „„„ „riui<. ir.gmo 1
evidence regarding the presence of taua w oiwtn ft on »« a J ar m ne jo
this apart from the actual demon
stratiou of the causative lowm The ba«w«\ weal and tnenva \wvUv a
chanicteristic picture in a well marked case
The Bahh m I » m \ should Ijc wseil first but prior to tl at a plain nulio
gram ma\ give some prehminnrv indication iF much gas is prc'^ent Tlic
presence of fluid levels should lie noted
Mith tlio Inruini enema the lower tlic obstruction tl e mom definite are
the signs liic dcmoiifetrition of ob truction bv tins method depends on the
arrest of the barium column at the obstruction and owing to tlie difliaiUv of
ensuring a i rcssure of aiiv moment m the c*cciim and nsctnding tol m a halt
m flow c f the tnem i at th it point is of lcs> significiiuv tl an in the desc-eiuling
cr si iiKid { rticfw In a will marled clicxnic olstnicticn in tie htfer
270
AI^TMEMARY TRACT
rcj.ions, the scquenec of c\ents with a tnnum enema is as follows The rectum
fills out normally, and the binum jiasscs in the usual waj up to the point of
ob‘»truction Continued administration of the enema then causes gradual
distension of the already filled gut, mtliout nu\ adinnce of the head of the
Imriuin A little of the enema max bo forced through the obstruction the
amount dcpentlmg on the sexerity of the latter At the same time the patient
experiences a gradiialh increasing distress and dc«ire to exacuate This
culminates if the adimnis
■ ' 1 tration is continued m the
escape of the enema p ist the
rectal tube
\\ hen these four feiturcs
^ are present — arrest of tin,
head of the enema iiicreos
mg distension below increas
mg distress and finall}
escaiw of the enema — a
diagnosis of ob>tnJct!on is
justifiable and is usiialh
correct oxen if tho nctuil
obstructing lesion is not
demonstrated The loxxcr
tho obstruction the more
diagnostic are those signs
l-'ortunatel> m most cases
the actual lesion is seen
such as the flUingHlcftf t of
a carcinoma the jagged ( on
tmcluro and barium filled
pockets of diecrticulitiH or
the wcklc eliaiied doltit of
oxtnn«it pressure and tlicsc
clinch the diagnosis
Fii 1 <S OKlnicli\(< anniilnr ranuuma of tho I ft
Imlf of ih c Ion hi »wn o iMmim mral
Tho nrl nl hito of tl c pruutli L4 V ui I proximal to
tl < ntncli rc tl colon u «lil itr>l nn 1 hIiotx a (1 ml InrI
It is often found in investigalingA^'**'”^ cawn due to caremonn tint the
obstruction to the entnn is greitcr than to « Inntim imal Kerlcy jMimts out
that the constriction tends to lie fiitinel-almi>cd, xntli the narrow end liolow
There nnj therefore lie a lendencx to xaixe action m a direction rctrogmic to
the noniial flow
Ini Rxnn m Mfai affords cxidcm-e as to the degree of stasis alioxe the
c-onstrutioii and the dcgrci c»f dilitotion It is safe to ii«c it when the
obstruction is hij.ii eg the ewum «incp inspissation of the barium will not
occur m that region In obstruction low down care mast Iw taken not to
cam the cxanmntion oxer too long a pi nod
COLONIC STASIS AND OBSTRUCTION
271
The appearances a banam meal a ary according to the site In csecal
obstruction the stasis is in the ileum it has been described in that saetion
When the obstruction is louer down, the first changes are in the colon On
following the banum in its progress along the colon, several changes are
ob-servcd The c’ccum and ascending colon fill t6 a \nde extent, but the
onward progress is slow Tlie trans\er«e colon, when reached, is seen to be
considerably dilated, and the haustml contractions large, ^vide, and few m
number As the region of the obstruction is approached the head of the
banum column Io«e3 its homogeneity, becau.se of its admixture with the trans
parent colomo contents in front of it This last feature is vera chanictenatic
Fig 190 — Ob3lructin„ cnpcinomn of llie colon with znarktMl
<ibitea->ion of tlie colon above (Banurn enema euputt* )
of oif^tcrfcfion, sn^} iW /nipeJj, if ta faiKtioiis} coioiiic sis^is In
organic obstniction the proximal colon gi\es the appearance of being “ packetl *
with banum In functional stasis the progress may be as slow, hut it i»
oliMous that the colonic lumen is poorly filled , portions of tlio gut between the
static seybaH are quite empty Finallx, m chronic obstniction the stenosed
passage may be outlineil, first with n mixture of banum and Peecs, and later
with homogeneous banum
INTUSSUSCEPTION
This condition the in\ agination of one portion of the gut into the lumen
of the iminodntely' distal part, IS infrequently referretl for N my inxc>tigation
VLIME\TAR\ TRACT
In most ca‘*es the condition ja urgent, the diagnosis ob\ious, and radiographic
e\nininatjon unneccssari If there is doubt as to the diagnosis and the
condition iwnmts a barium enema mo\ demonstrate the lesion
The great majontv of cases occur m joting children and m them constitute
a common tj^w of acute intestinal obstniction It is a rare condition in adults
and in them tends to be chrome and mtcmiitfent
Pathological Anatomy — An intussusception e^onsists of three concentric
tidies
(I) The entering tube
(J) The rctuniing tube,
(3) The reccumg tube or sheath
Hit first tico eonstitute thointnssusceptiim and the last theintushuscipicns
The junction of the entering ami retiimmg tul>o forms the ajicx of the intiissu-
oeptum and the junction of the returning tube and slieath is called the noch
The moM*nter\ is dragged in I»et«een the retunmig and rcceuing lajors and
as it becomes packed therein occlmles Us contained blood ses&els and caiiscs
gangrene of tbe intussnsccptnm The drag of the mraenterj on the mesial
side of the intussusception causes the t>ptcal contaMt> of the tumour mass
felt ehmcall}
Classification — This is hasc<l on the |>ortion,s of gut mrohed The
common t\’pe is the entero colic tmoKing l»oth small and lar^o intcstmc
Rarer \nrietiessro the cnterit and the colic iiuoK mg small and largo lnte^tl^es
resjiectiicK Tlu great majority of eases m children occur m tlie ileo rical
region and therefore fall into the entero colic group Depending on the part
forming the a^wx of the intusausceptiim throe types occur
(a) The i!eo-c(tcnI in nlitch the ileo-cTcal ealro forms the apex This is
nimh the commonest form
(li) The lUo ro!ic, in nhich the ilemn forms the apex and
(r) Dio coral in which the inverted cecum forms the apex
Die Mirioiis tsjics mac be therefore tabulated ns followH
(1) Intcnc
(2) Fnferc) colit (n) Ileo colic
(b) Ileo cacal
(r) ( icnl
( 1) folic
Ladd and Oro-i hast annlvscd a senes of 372 cases m children The
|xak age incidciu-e m thc'e was 7 months and the porrenta,.© of t\pes ns
follows
I( •< -fircHl nn I rts-nl
ll»r>co|r If
f 1 .• -Ml
In tlic r.n it mnjoritx of the t eases tlu dis^iiosH was dimcnll> ccidcnt
•iscs in which there was nomc doubt were submitted to
COLOMC STASIS .\XD OBSTRUCTION
273
Mnum enema examination \ correct diagnosis n’as made in sixteen
of tlie«e In one an i!eo ciecal intussusception no colonic ahnormalitj
was found
Radiographic Features — Although the diagnosis of acute lntU 2 ^susceptlon is
usualh cudeiit climcall) and requires no icnfication the \ rt} appearances
Fic 200 — Intu'* tsfcpt on in a chi S astnl 18 montlis
|n) Ti c barium enema ob<»tructc<l bv the B|«cx of the iniuMtt«cpptujn producing the char
BCtcntlic cupping (6) \fter evacuation of tl c incma troooi of barium have e»cnj)«l into tho
hi cll or int is>nwc | ens
arc so characteristic that a barium enema should be given if there is any real
doubt provided the patient » condition permits
In a tjpical ca«ie there will be noted the follovnng abnormalities (Figs
200 201)
(1) Obstudction to thf Enfma — T lie enema runs normallv up the
colon till it meets the apex of the intussu-ceptum at whicli point it
IS arrested
(2) CuriiNC oi THE Head oFTiiFfiARitM — ^Tlie apex projecting into the
arrested barium injection causes an indentation or cupping in the banuni
shadow at that jxmit
(3) hiLiTNo OF Till Inti sstserrnoN — ^The obstruction to the enema
caused b\ the invagination is not tisualK nlisolute Groduallj a thm incom
plcte cvhndncal shell of barium spreads lietwecn the receiv^ngJMuljTtum
\ R TI— 18
274
ALI5IEXTARY TRACT
mg Kjers of the intuss»i.sccption Although theoreticalh a centml streak of
bannm might escape along the hiinen of the intuxsusceptom, nt-tiiall) tedema
usnalh ‘*ecnis to pre\ciit tlu"*
(4) L^>CAU'SATlO^ OF THF TiMOun — ^By rac!tO'<copic palpation, the tumour
felt tlmieall} can beshoAv-n to conr^pontl to the barium shell
(5) Ri-simri AFTtii EAACrATiON — temls to remain entangled
lictucen the sheath and nitussusceplum after the bannm has been e\acnated
Several ob'-crvers have noticed a spontaneous reduction of the intiissiweep
tion during and appircntli ns a result of the pressure of n Innum enema
This IS a fortunate otcurrcncc, and one which can be followed throughout its
course fluoroscopicallv, but it is too uncertain to warrant the tw of an opaque
enema for that purjw'se
Indeed time is so much the essence of the contract of safetj in these cases
that none should be wasted even on a diagnostic opaque enema, unless the
doubt as to the diagnosis is real If, however, a diagnostic opaque enema m
decided upon it is worth while attempting, by gentle abdominal massage and
gentle thud pressure h} the gravity fed enema, to reduce the invagination
The two criteria of success m this manoeuvre are the unfolding of the colomc
reduplication seen b\ the filling of its lumen, and the escape of the enema into
the ileum Even if recluctiori is complete narrowing of the colomc lumen will
l>e evident from (edema of the tolomc wall
After fluoroscopic reduction the child must be kept under ver^ strict
observation in case the reduction is incomplete or the condition recurs
VOLVULUS
The term volvulas is applied to the twisting of a segment of bowel on its
me-cnterii axis liie sigmoid colon is the portion involved m the great
nmjoritv of cases — 7) |ier cent according to A 2UUa This segment is
particularly prone to vohndiiv liecausc of the aigma shape of its mesentery
In the greater miinlwr of cases the condition constitutes an acute surgical
emergency l>eing one of the most fatal forms of obstruction Not only does
the twibt olKtnict the hovrol but it also cuts off the blood hupplv and cau-es
gangrene of the afTeetcd portion
In a few rare cases the olwtniotion is incomplete and the vascular supply
intact In these cases of chrome volvulus radiological examination may bo
of help The how el up to the neck of tlio volv ulus can be show n w ith a bannm
enema and if any of the enema can escape through the neck a sickle shaped
shadow may Ik? visible leprescntmg the narrowed first twist of the distal limb
of the volvulus In addition depending on the degree of ohstniction gaseous
distension mav he evident alaive Obviously a bannm meal mi^lit l>e a
dangtmus method of examination in these eases
ALniE\TARY TR \CT
GALL-STONE IMPACTION
Gill stones of a stre (1 intlj or more in diameter) sufficient to ciuse obstruc
tion b\ impaction in the small intestine ore usuolh to some extent calcified and
so visible m a radiogram Except in xerj rare cases the gall stone reaches the
intestine bj ulcerating its through the gall bladder and adherent jejunum
and it usiiallv impacts m the lower ileiim The larger it is the higher the
impaction It maj therefore be visible in the right iliac fossa in a pi iin radio
grim taken to determine the site of the acute obstruction winch is the usual
sequela of iminction
CHAPTER Win
TmiOURS OF THE COLON
BENICV TUMOURS OF THE COLOV
'solitary Tc^corRs such as adenoma fibroma lipoma orni^onn are nre
Thej usually become pcdimculated and project into the lumen of the bouel
If large enough thej maj show a mobile central fillmg-ilefect anth a banum
enema but thej may easily escape detection In this method Thev can l>e
demonstrated uith greater certamtv b\ one of the double contrast methods ,
hut even when one of those is
used a negati\e result does
not exclude them with cer
taintY
Multiple adenomata {njn
polvposis of the colon) maj
be present in large numbers
and maj co%er a large portion
of the colonic mucosa At
first tlic\ arc small flat and
sessile but some mn\ grow to
thesizcofachern and become
polypoiil ClimcaUi the> give
rise to intractable diarrlicci
painful tencsnnis and blood
and mucu^ in the stool
Ulceration and malignant
degeneration are common
fieqaeti'c
^omo indication of the con
dition nm^ l>e seen in the
contour of the banum enema
{ucture in the form of small rounded indentations but the adenomata
are Iwst demonstrated bj one or other of the double contrast cnenmta
\lith tlie&e methoils the opaque medium settles in the crevices Ixjtween
the tumour masses and produces- a coarse lacc or honcvcomb pattern
which IS almost pathognomonic {Fig 202) -Vs tlie mnscular coats of th»
bowel are not involved the lumen ij> not narrowed and the nortnul
haustration is present
278
ALl\ILNrAR\ TRACT
CARCINOMA OF THE COLON
Till** 13 a common disca»c and one in ^\htch the help of tlio radiologist is
sought 03 a routine The signioido‘«W)pe is mthin its ambit the coiulusive
diagnostic method but radiolog> is the moat accurate method for the colon
abo\ e the reach of that instrument Tlie itiethoil of choice is the hanum onemn
for reasons nlreadj enumerated
Morbid Anatomy
hrom the radiological point of \iew it is the macroscopic \arietics uluch
are important
The commonest tjpt is the ndtt o caret! oma originating in I lelxjrkiihii a
glands This mas form a tumour mass jirojecting into the lurA^F'-aihich
coinmonh ulcerates sooner nr later
Tlie srtrrhoHs tj pe tenda to encircle the bowel and produce a ste^ “*'* ^he
contneturemvj m%olveas(.gmcntoflIiegnt2 Sincliesmlength
to a ser} narrow ?one — the string carcinoma Frequently a
//mc 1 Kicro^coptc hjpen occurs with projection of a tumour ma*^ into the
eolotuc lumen scirrhous contracture of its wall and an ulceration of the
projecting tumour or the colomc wall In the stenosmg tyivj the channel luaj
lie reduced to a crow quill without acute oh tniction suponening
The low el hI>o\c tie loton h frequently dilated and hyqiertroplucd
Site
Tlie jielvic colon is the commonest site of carcinoma next the cTCuin and
ascending colon then the tmnsveivc colon and splenic flexuro and lastly the
hepatic flexure and descending colm
An9chnl and horle hasc rejiortcd tie following site mcidonce in a senes
of S'*" I o-scs
Seno I -138
Cut n pn lu jr rolon sn I hrnal o H<-ii re 5 C
S| l^^ <■ flpx re 1 cn i nK rol n 1 1 1
Trna \ rw "ol I
Radiographic Features
'll e inrdiiial feature is the pre cnee of a filling defect in tl e barium filmdow
The other signs arc the jire coco of cnlonic obstruction fixation of the gut
entcrosjasm an 1 liisturlnnce of the colonic mucosal j attorn
Tufc. Fiutno uvvect — ^llns max be of xnnoiw t\j>es depending cn the
size sliajH? uiut tx i>e r f tlie groieth A tumour which projects into tlic lumen
prtwltices a defect rf tie fitter prtit tvi»e similar to that produced by an
cncephiloid cartirionm of the stomach Tlte ctmtour of the gut is almost
mxnnabh iinolved nK) liccause of the rcHtncly small lumen If only n
<-entral filhngwleft ct is \isililc ftoal accumulation or a polypus is much the
TUMOURS OF THE COLON
279
more protablo explanation In the ciccura however the \nder lumen niaj
result in onl^ a central defect being visible
In the majority of cases the fillmg defect takes the form of an irregular
narrowing of the bowel The vapltn ring defect is a very typical appearance
In this the normal lumen is abruptly interrupted bj a narrowed portion of 1-3
inches This narrowed portion is commonly shghtlv excentne clue to the
greater mass of the tumour at its point of origin Two features of tins tjpo
of filling defect are its sharply defined and rather jagged or irregular outline
and its constancy These distinguish it from a localised colosjwism
hen the annular scirrhous grow th is limited to a a ery short segment of the
bowel the type knowai as the «tnng defect is produced as though a h^aturo
had been tied round the colon Even in tins !ocah«5ed defect the contours of
the bowel where thej dip down to the constriction giae evidence of their
imohement in the growth bj their slight irregularity and by the constancj of
that irregularitj in a series of racbograms The constancj of these defects
such an important point in tlieir evaluation can be tested by siipcnmposition
of the radiograms Although perfect fusion is usually not obtained bj tins
procedure the deformities will show the same geographical features
Oraham Hodgson has drawn attention to a simple test for the constancy of
a filling-defect— that of taking tw o exposures on one film at an interval of some
few seconds Tho normal portion of the banum filled gut will show a double
outline owing to peristaltic action the filling defect either carcinomatous
or divorticulitie wall not
Attention to one tvpe of filling defect has been drawn bj Lockhart Mum
mery It results when a sessile adeno carcinoma ulcerates m the centre When
this is seen in profile there is a double encroacbment of the colonic lumen
smee the edges of the crater are somewhat raised In contradLstmction to
this the papillomatous growth procluces o rounded filling*<lefect
IiiE BABiPai Enema is the method of choice for the demonstration of a
carcinomatous filling defect Onij b> it can the whole of the large bowel be
filled with ccrtaintj and even when fillet! certain coils tend to overlap and
obscure each other In the eigmotd this is a common occurrence and a growth
just above the rcctosigmoulal junction ma> be completely hidden m a postcro
anterior view The right oblique view usunlK separates these two shadows
and should lie u«ed as a routine m oil banum enema exammatiotis Occasion
allv the left obhipte anew is more effective liccause of the disposition of tl e
sigmoid and if the former oblique fails to show a satisfactory separation of the
coils observed fiuoroscopically the other should he tried
it 0 e sphme flexure a similar nxliiphcation of tl e two limbs commonly
occurs and this region presents the further difficulty that it is quite inaccessible
to palpition \gam the optimum degree of rotation mu«.t lie determined by
'•(even e-xnminaiion but ns a rule the left oblique position is the best
The hejyitir flexure is acc-essiblc to the palpating hand and a lesion there i-.
. J (lowing
-~\iinul<<r rarrinoma of «h« 1 lo \ I no-cnmnetna of thf Nijmoj
<i(K<or»l ns colon f riser jirmt tlert>ctii
\nnular cnmnonui f f jfic *rs)n<Ml im *ccti lo tl«* nevi n 2 iiucc of « Ihonum tl rf-
itlnto ennmi Tlic rnn«-o~al i4 aticni m Ihc hHtjccI
TUJIOURS OF THE COLON 281
inotx3 easily detected The ctrcHW often presents some difficulty, because of
tbo size of its lumen and the difficulty of filling it uniformly. In spite of
thorough preparation, the cascum may contain a considerable quantity of fluid
ffcccs, ■which ddutes the barium injection and causes a mottled or mcgular
shadow Careful fluoroscopic palpation should reveal the inconstancy of this
appearance, and so its nature.
Appearances uttk the Tuortum Fixjcculext Exesia — ^In some ca<5es a
small evcephaloid carcinoma is hidden by the overlaid shadoiv of a barium
(n) (t)
FlO 20G — Encc|jt>aloi(l carcinoma of the sigmoid
(<i) Filling dcrfct in the filled colon (&)I{eticfpa(tcmortheluTTiotiranprc\aciiation of the enema
iumtiiO- Jt isjlUAUC'h tiiat the aill.'ijiscd and inflated stqrres of a fhoxmui fuiaoxo
may be of a nine
The segment of the colon invatlcd by the tumour is rigid and does not
collapse readily. If by jiosture and massage it can bo made to empty itself,
gas is apt, acconbng to J/niHgot, to accumulate there. No plicie are visible in
an invaded area. In their place is on irregular disorganised areolar arrange-
ment, u itli clear areas and opacities corresponding to the tumour masses and
the interstices lietween.
Inflation 'VA'ith air show s the tumour ma.<w In greater relief, an efiect further
enhanced by stereoscopic radiograms. Tlie inflation also reveals the extent of
narrowing of the bowel resulting from the neoplasm.
282
ALPtEXTARY TRACT
The anttular setrrhotta camnoma of the colon usuallv «o evident ■mtU a
banuni enema that it ls unnecessan to u«e the more complic-lte<l metho<l,
unless overlapping of coils obscures the lesion
The fitenosed pa« age is of eourec clearly visible ba the thonum method
CoIIap-e of the gut aboae the groaath is usnallv preventetl bj the stenosis
present That below tho
growth eoIlaiHes normallj
and shous a normal mucosal
pattern or one showing a
reflex reactive state The
steiiosed passage shou'a no
phee Air inflation shows
up the stenosw «nth partieu
lar clanta
The double contrast
enema either barium or
thonum finds its particular
sphere or usefulness m tho
doubtful case — one in which
there is 8.a> an unexplained
colonic ha?moiThage and m
uhich an ordman banum
enema reveals no causo fur
the bleeding If b> the
more comphcaterl procedure
an occasional ear]> carcinoma
15 (bscovered the method is
well worth using even
although manx a hluuk is
drawn Uecauseofthi possi
bilitx tlic method constitutes
a definite ad\ ance m the earls
diagnosis of carcinoma coli
DrrFLRENTiai DiAoao'*is of thl Iilltno xiEtrcr — Pcvcral other coiuli
tioiis mas product a gap in the haruim vbadow notabis diverticuhtH
TidaaYitta\ ■ci\tt'nAv»e ^u’ca^ ^TjWmAovis nrtmnms ct> is wnrifie\-onnT/ftTs
circum«onbcd appendix nli^eess colospasm focal concretion*’ and gas "Most
rf t!ic*< are recognisable but <!if!icult> raaj nn-m with ciecal tulxrculosis and
nctinonucosH It mas lx; quite impossible to dilTerentiate radiograpliiralh
cancer tubercle and actinomscosia of the c^ctira and the dect«ion
mu t then !». amsed at on clinical evidence or biopss
In the ca-caiin the «itc where the greatest diflitults an-^** in the difTerentml
diagiiosus certain ft attires mas lie of help
1 in *07 — rrln u« camnotiw of lh«* cTcum •nd a'*ccn I
ms colon null Ini oWnu-tion *hown l> •bsnum mnl
hour* after on ITii* [ alKmt tis i at the ratne
l TiH o ixiiThou* growth of the »toniA(.l
TTOIOURS OF THE COLON
283
Encepbaloid gro^-th** cause a ra^d, srorm-caten filhiig defect Scirrhous
growths produce a more regular contncture closelj similar to c'ecal tulier
culosis , an appendix abscess
causes a smooth regular one
Ileal stasis maj occur mall three
in the following desccndmg order
of intensity carcinoma, abscess,
tuberculosis
Any bubbles of gas that inn}
be presen t d unng a ba n u m enema
tend to collect, in the supine
position, at the apices of the
colonic a\aterslieds, namely the
highest loop of the sigmoid and
tliD middle of the transverse
colon They are distmguisliable
from neoplastic central filling
defect b} the absence of an}
deformita of the wall of the gut,
and b} the fact that the} are
more transparent than the
surrounding soft tissues Change
m posture— e g to the prone
— oompletel} altera their <bs
position
Fojcal accumulations and
concretions may cause more
difficult} , and re-esaiiuiiation
ina} be necessar}
The distinguishing features of
duerticulitis, ulccrati\e colitis, pedunculated simple tumours, and colosposm
are described under their respective sections
Obstructiv f Signs rs CancisOM^ of the Colon — Too often this feature
is so marked when the patient first seeks advnee, that radiolog} is not
emploved, the case goes stnught to the theatre ns an cmergenc} Of the
hnlanc-c the majont} shou some evidence of stasis above the growth In
many of these the degree of obstruction is sufficient to make the use of a
)>anum meal unwise, but in other milder degrees tJie barium meal mav lie safe,
and give useful evidence as to the degree of back pressure
*1110 general radiographic signs of colomc obstruction are described else
where, and it reninins onlv to be said that in carcinomatous obstnietrori the
nitual obstructing lesion can be demon'>twttd b\ a binum enema in all but
the most severe c ises — tlio^c bonlenng on the acute
f 1 C 209 — Carcinonra of (lie irpciim csiuirura filJinff
aleXert llicrcof Lllpa^□tom^ rev^alini eccon Inn
deposito in the loor
ALnrCNTARY TRACT.
IrvATioN OF niF Gnownr — Tins as determined bj radioscopic palpation
diinng an enema e\amination is a late sign In the earl> stages the anbeted
portion of the colon shows normal mobility, and only Avhen the neoplasm lias
spread to stirroundnig structure docs
^ nyation take place Its cliief signifi
IS therefore os an indication
of operability ortherc\ersc
EvTEnosFASM — 111 certain ca.ses
ulceration of the grow-th causes adja
ccntspasmofthecirciilarilbres which
modifies the fillitig'dcfect It is seen
espccmllr in the sigmoid and ninv
cause a temporary obstruction to the
1 ^ gSKK enema Intcnnittcnt appliiation of
E nomiil gravity pressure of the
^ ' * enema usually causes a rclavatioii
The prict ical importance of this sp^sm
!•> in the (lifficiiUy it ma\ cau e in
demonstrating the more «enoin under
hing lesion
Perforation of a Carnnomatoiu Ulcer
Tins constitutes a surgical emcr
gtncN and the only occasions on
winch tins IS demonstrable radio
grapliicallv arc when the perfontum
occurs accidenlalK during the cour«e
ofa Inriiim enema examination This
mishap ma^ take place wit «t on\
undue enema pressure if tne nicer k
already near the point of perforation
and constitutes a warning against
using too high a grasits head in the administration of the enema The
fluoroscopic appearances are charactcrLstic the banum is seen to pas-s along
the colon norinalh to the pc mt where perforation occurs and thence in a flood
into the pcnfoncal canty
Ihc onh thing tint can be isaid in mitigation of this nnhapps occurrence !■»
that the incMtalile perforation is discovered at the earliest possible moment *
'*09 — Care nninn of ll c losi (*i
M th in { lent perfornt :
SARCOMA OF THE COLON
This H a ran. dtscast and is most freqiiciith met with m voiing feiihjccts
It iiHiialU involves the CTcum It tends to infiltrate the bowel wall and convert
it into a rigid lid»e oli'truction is n late plicnonienm It is inipas.'ible to
differentiattit mdiograpbicallv with any certainty fromaenremom itousgniwtli
CHAPTER WIV
DIVERTICULITIS OF THE COLON
CLINICAL FEATURES
Definition — llua condition consists m the presence of small protrusions of the
mucosa through the muscular coat and the formation thcrebj of biiiall
saccular pmieliea Inflammatorv changes commonlj super\ene in and round
the di\ erticula
Terminology — Althougli the term diverticulitis is commonly used to
include all the stages that occur m this disease it is convenient to describe the
pre inflammatory stage as one of diverticiilosis and to restrict the term
div erticulitis to those cases m which inflammation has occurred and vrhich
consequently give nse to symptoms If the view of ^prifjs js accepted to
those thero ma\ be added the pro diverticular stage
etiology — ^Tlie precise caii«e is unknoirn It a dj«ease of the Jater
decodes of life few ca.ies occur before the age of 40 and its incidence is pro
gre«siv elv greater wath increasing rears In the writer s evpcnence males are
more commonU affected than women and the condition is much more common
m private than m hospital practice A spastic c-onditiou is held by bome
authorities to lie a factor in initiating the early mucosal herniation and the
iinjicrfect nature of the outer muscular coat of the colon doubtless makes it
easier for the protrusion to occur
Spriggi found in 3 000 banum meal or enema eaammations that 10 per
cent showed evidence of dn erticulosis and 2 3 per cent ev idcnce of diver
ticuliti« Associated cancer was found in onlv four cases Tins last is within
the limits of coincidence The average age was 5C the ratio of men to women
v\as«>4 16 and one tliml of the patients were obese
PATHOLOGY
The protrusion commences ns a tinv \ sliaped mucosal process winch
w hcrev er it passes through the inner muscular coat enlarges into a flask or
currant slnp^ saccule with a narrow neck The herniation always takes
place along the edges of the ta?nm (at points v\here the blood vessels penetrate
the muscular coat) and never through them The wall of the diverticulum is
therefore formed of mucous submucovw and pcntoncal coats ‘^metimcs
the diverticulum penetrates an appendix, cpiploica and so acquires a fatty
coat as well
The divcrticiih range in sir^ from I or 2 mm to aliout 2 cm The majontv
\LrVli:NTAR\ TRACT
2*^0
are about |-1 cm m diameter The> ate generally held to l>e |nilsion dj\cr
ticuh herniating through veaK points in the l>onel ■wall Their tendcnc\ to
develop alxivc a colonic ^tneture is quote<! bj Loclinrt Mummtry m support
of this ■nc"
Site — Dntrticula ma^ occur aimihere in the ctcum and colon hut In
far the coninioncst hitc is in the iliac and peine portions The most frequent
dLstnbution is a con iderible number in the sigmoid and a feu scattcrcfl
elsewhere Lsualh the^ become pn>gre*snel% fewer as the colon is traced
uiiwanls In a number of cases the^ are limited to the sigmoid and even
when they are aKo prc'^nt elsewhere the stage of the disease is more advanced
in that segment the dnerticula are more numerous larger and inflammatora
clianges if pro ent more severe Occasionally a diverticulum may develop
in the appendix Aceonlmg to LorUari Mumviery they do not tend to
develop patliologital changes in tins situation Ihis is a curious fact if tnie
ill view of the tendency to formation of concretions m the appendix itself
Inflammatory Changes — Sooner or later in the majontv of cases the stage
of diverticulitis is reached The c changes ore almost exclusively limited to
the descending iliac and pelvic portions and e8)ieciall\ to the latter The
inflammaton stage is initiated br stasis in the diverticula 'tcybala tend to
form m the iwuches and if thev l)ec<»me sufficiently lapissatetl tier are
retained and sot up catarrhal changes m tlie same wav that an appendix
does if it contains a concretion
These early inflammatorv attacks mav sub ide without causing much
stnutuml change again as m catarrlial appcndicitLS but in time the sub
niucxml coat l»ecomes mvnlve<l bv the formation of minute intra mural
nlfscesscs Tlie wall of tlic gut adjacent to the diverticula also shares m the
process The ivntoneum reacla to the irritation m the form of a plastic
pentomtH In an estnl li*>hc<t case it liecomcs lliickencd and the diverticula
tend to l>ecoinc pnrtlv or complclelv submci^ed in the hyperplasia The same
process i-aa es a narrowan„ of the lumen of the gut In all but the advanced
ca>«e8 some of fins narrowing seen nnliographically is however due to apa^m
of tl e circular muscular ccxat and only part to orgamc stenosis Tlic mflam
inatorv hv jierj lasia at counts for the eau^age shaped tumour which is frequentiv
found on (liiiira) examination Penfonea! adhesions commonh occur in the
later htngps resulting in fixation of the nffccted segment Perforation of a
dncrticinum or c>f an intra mural abscess mav occur but Ijccauso oT flic
adhesions general peritoneal infection is not so common as in a perforated
appendix llie pcrfi rvlion may take place into the bladder or may result in
a Iocali>cd nl sccm
^tcriovis of the colon commonh resulta when the stage of the sausage
tumour is reached It mav bowcTer occur from pcncolomc adhesions or
from a smooth intnii'ic flbrotie stneture without hvperplasia In this last
Ivjie the diverticula mav l>e so comprcsKxl that Ihev do not fill with a baniim
DREIITICULITIS OF THE COLON
2S7
enema and the narrowing may be mistaken for a scirrhous carcinoma This
IS the 13710 most amenable to surgical excision
Lockhart 2Iummery has summanved the complications of diverticulitis as
follows
(1) Tumour formation
(2) Absce<<s mtra mural or pencoloiuc
(3) Colomc stneture
(4) Pencolomc adlie^ions
(o) Fistula; eepeciall3 vesico cobc
(0) Carcinoma (he holds that divcrticuhtis pn disposes to carcinoma ,
new at \anance mth those of Spnggi)
(7) General pentomtis
(8) Contracture of the mesosigmoid
RADIOGRAPHIC TECHNIQUE
The preparation of the patient b3 apenents and colonic lavage is im£K>rtant,
the object being to empty the diverticula Jf there are clinical signs of active
pcndivcrticuhtis with the pre ence of a tumour mass it is unwise to use
drastic purgation The diverticula are devoid of a muscle coat other than, the
musculans mucosa and it may be dilhcult to ensure their empt3’ing by ant
preparation if their contents arc inspissated This diflicultt may be turned to
advantage in estimitmg the seventy of the condition since stasis in the
diverticula is of clinical significance and the stasis can be demonstrated in a
bnnuin enema b} tlie bubble or flask sign
Two methods of investigation are available — the banum meal and enema
Tho‘% w ho favour tlie Oartiim meat method state that it fills and so outlines
the (bverticula with greater ccrtaintv than the banum enema and this is
probabl3 true The meal al o indicates the degree of colonic stasis above the
inflamed segment It lias however several disadvantages (1) It mav
aggravate a chronic obstruction (2> It usuallj fads to give an accunU
picture of the degree of the inffaminatorv change present and of the extent of
the stenosis (3) If onl^ a few diverticula ore present it mn3 be difficult to
distinguish between them and mtra luracnal sC3baln (4) The examination
mav last several davs
The Oanum enema sufTcrb from tvro theoretical objections — namelv that the
diverticula do not alwavs fill so well and that the wadel3 filled colonic lumen mav
mask some of the diverticula It is \erv rare however in the writers ex
pcnence that none of the diverticula arc filled vnth a banum enema and failure
to fill some of them is not of senons importance The masking can be mmi
miseil b} taking radiograms in difTcrent planes Tlie enema gives accurate
mfoniiation regarding the divcrticuhtic iilling-clefect shows a pre-diverticular
8pa«m fills the nnjontv of the divcrticaia and demonstrates diverticular
288
ALIMFVLAUY TR Vd
ficj bala Jlost of the fttl\ antages nfTordcd bj the meal metliod can be attained
h\ cxaminuig the patient again tuentv four Wirs after the enema examination
In the wTiter s opinion therefore the baruim enema should bo the method
of choice in all ca‘ies of di\crticu!osis and di\erticuhtK and the meal rc'<er\ed
for ta<:ps in winch the enema fads to elncidato the condition satisfactorily
The enema sliould bo administered in the onlinar^ waj under fluoroscopic
cotitrol and particular attention paid to the jielvic and iliac portions of tl o
colon The duerticuK if small nia> be dilficiilt to see under the screen but
anj sfenosed segment is iwiialh \isjblo and its mobility and tenderness to
palpation should lie tested Ratbograms in the jHistcro anterior and oblique
McwH should 1)0 taken and one immcdiateh after evacuation of the enema
The evamiiintion is ustiallj completed bv a further radiogram twentj four
Itours later
If the barium meal is usetl tie chief ixiint of impmtanco is that the
examination should be contmued daj bj daj until the colon is clear of
barium leaving onl^ the barium filled diverticula This maj lake as long as
a week and the ilemonstration niaj be rather acidemic for the trouble and
exjiense involved
In cases of difficultj and particularly when H is desirable to dctulo a
doubtful associated mllammator> change in a ease of divcrticulosis the double
contrast biniim air enema ma> lie used or better still the thonum air
three stage enema Iho particular advantage of the latter is the indication it
gives of the number of diverticula and the stale of tlio suimunding mucosa
Farl} infiammatorv changes can Iw detected bj this method wlientheordinarj
liarnim enema gives no indication of their existence
RADIOGRAPHIC FEATURES
I he barium enema gives such a vrealth of information about a case of
diverticulitis compared with the Imnum meal that it is eonvement to ksenbe
the enema appearances first and then to add anj additional pomta demon
strable hj the other method It is also convenient to describe tl o appearances
stage b^ stage although in am one case several stages nm) be present
i-ontcmfioraneouslv in different sections of the colon
( 1 ) The Pre diverticular Stage — Tins has been full^ described l\ Spriggs
It IS showai bv a barium enema «iil> and consists of fine spastic notclies either
grouped on the summils of the liaustral bulges or replacing those bulges
(tig 210 (a)) riiev arc not unconinionl> seen m carl} cases of divcrticulosis
111 segments of the colon which arc devoid of visible diverticula Their
sigiiifitanc-e is the suliject of some difilrence of opinion Barclay attaches
little importance to the apjK'aram'e Spngy^ holds that it is a true pre
ihvcrticular stage spastic in nature and that the mmiite spikes represent the
incipient I cmiation of the miieosn Lock) art Mtimmfry Graham llotlj^on
and DhAci have shown bv histological section that the tinj notcics arc
DI^XRTICULmS OF THE COLON
289
actually cluo to tins Ikj
ginmn,' herniation In !iis
clinic, Spriggs his had the
opportunity of observing (n)
some of thc«e cases over a
number of 3 ears and lias
noted the subsequent
dev elopment of diverticuli
in segments of the colon
\\ luchprev io\isl 3 presented
the apiistic appcirance
In the present stage of our
knovi ledge the theorj he
holds provides the most
reasojjible explanation
nieteiufencv towlonic 2IO— Dw?rflmof(o)Ptwl»erticuUrop(wm (fc)De>elo{>«<l
spa«m in diverticubtia is dncrtHmltu tooth efTcrt and Altemato notching
homo out b> the difficulty
ttj _il — Dncttioulo#w
\ n JI— 10
that IS frequentl 3 experienced in
adnunistonng the barium enema
m these ca«cs In many cases the
sigmoid goes into spasm ns soon os
the rectum is filled so much so
that the '‘0 ci«es acquire an un
liappv reputation amongst the
nursing staff of the \ rav depart-
ment ’
(2) Stage of DiverUculosis —
This 13 charictensed bv the
presence of banum filled divert!
cula , rounded opacities, varvnng
m size from l~2 mm to 1-2 cm
and connected to the colonic lumen
bv a narrow neck (Fig 211) An
apt simile is a currant vnth its
stalk '^omc of the diverticula
mav alroadv be so completelv filled
w jtb stercobths that onlv the stalk
fills with barium ^lore commonl}
a film of the opaque emulsion coats
the surface of the contained sev ba
Ion and produces a characteristic
ringed shadoH liLe a bnlibJn nr
290
ALI’MENfARY TRACT
plasi flasK Frequentlj onlj tlit provimn! half of the duerticulum ls coated
hanuni creeps half round it, an<l produces a characterii,tic crescentic oi “ wine
glass shndou
(3) Stage of DnertIcuUtis — It js not untd this stage is reached that synip
toms of nn\ consequence arise, and its recognition is of «omo importance (Figs
212 214) It is characterised bj changes in the lumen of the bowel rather than
in the dncrticula T/<c (hangei t« Iht dneriicula, if nnj, are an increase m the
FiCi 312 — s ijni 1 1 ilivorticuIttH altnwn t \ ) >num Hic aau toolli jtoUliins mm il lo,
m iiCBtins ()■'' inflnmnuitorv stast*
number of flask shadow- and the oblitcntion of some of them The clanger
in the lumen are quite distinctne in a developed case
(o) It IS imrroued
(6) It presents <i Jigged or saw tooth contour, the apices of the teeth
fomcidiiig with dnerlicular nerks A serj characteristic ■vanition of this
appearance l^ an nltcnmlo notching with a diicrticulum at the intcr\enmg
Tlw %•.».«<. U'/i v.w:to>».c<A Vm-wo. o. (,Fc" ilQi In, ad
lanced case*, the diicrticula maj lie ohhtcmtcsl at the site of the inflammatory
change'* and the apjicomnce may then resemble o carcinomatous filling defect
Usually lioweier, there is soflicient of the notched or saw tooth appearance to
indicate the true nature of the condition c\cn if no dncrticula arc risible
el«cw here In this class of case the banum meal may bo of real helj) in filling
diierticuli which an, inqKrvious to the enema
(c) important feature of the inflaminatory change is the constancy
S91
1 lo -13 — S Kmo 1 11
292
ALnrCVTARY TRACT
of tlie filling defect Sujierimposition of a ficries of ni(liogtam«! reveals an
idtnticnl outline in each allowing for variations in the distension of the lumen
hj tlie enema In the well marked evse even considerable distension faiN to
produce anj change, since the walls are tluckened, fibrosed, and inelastic
riif sjiastic phenomena on the other hand, arc susceptible to some alteration
from V ariations in distension and spastic tonus
Tlie doublc-exjiosure method described bj Oraham Hodgson is useful in
denionstmtnig the constant inOamniatory deformities of contour It consists
in making two light exposures on the same film at a few seconds’ interval
V*inpilla »l»n II iHt’dlvtrtliJom C etrrlnft a
t ici 21*1 — CarrinomA nn I ilmrtJciiltH in atiino paac
Might nlierntion i** seen in the normal liowcl and none m the. diverticulitic
hcgment although not ncit •‘•wirj in cverv cose it is of help in a ease of doubt
fill iiilhmmatorv clnnge
tartinoina tnav coexist with or 8ii|ier\cno on tv diverticuhtis and ma> then
prcv.ntaver\ difiiciiU diagnostic problem (I’lg 215) Since the priniarv ili^oaso
( an product a radiognipbic filling defect wnnhr to a carcinonntous one {e\ en to
obliteration of tlie ilivcrticular similous) it is usually diirutill and wnnofmus
imj>os,sibIe to detect from tbe ndiogmphic appeanneo* the occiirreme of tins
serious complication The onh safe course in a rase of serious doubt h to act
on the assumption that the worvt has hnpj»ened, and that a cancer has
dev eloped on to]> of the original lesion
DWERTICUUTIS OF THE COLO\
203
Perforation — Perforation into the free peritoneal ea\ itj is an acute
surgical emergenej one u Inch does llotpa^ a visit to the X ra> department
en route for the theatre Perforation into the bladder is readily recognisable
Pjo 210 — lorfomtion of d vcrtic tlum mto tie bladlor
cUnicallj, and can he dcinonstmted radiographically b} the passage of a
contrast medium from one n iscus to the other (Fig 216)
Appearances after a Barium Meal
liio patient should be eaamined twenty four hours after taking the meal,
and on succeeding dajs ns necessary
Tins method shous tlie di\crticula \erj w'elJ and demonstrates colome
stasis if present, but gi\cs little or no information regarding inflammatory
changes In a uell marked case the diacrticuK are seen filled uitli barium
tl«e (Pig 217) If onl\ one or two opacities are present it may be difficult to
dctrnniJie nhethcr they really are in diverticula Banum in a diverticulum is
evtra lumcnal and to prove that it is outside the colon proper the lumen of
the lattermust bo full} outhnerl Bcc«u^e of a tendency on the part of banum
sulphate to cake these diverticular shadows may remain for several days, a
further iKuiit ilistmguishing them from scyhah Stasis of barium in them
should not be rcgnnlcd as evidence tliat similar stasis occurs with ordinary
frecal contents A better index of real diverticular stasis ls the flask shadow
mentioned above
294
ALniLXTARY TRACT
Appearances after a Thorium Three*stage Enema
Sucj oj Dn tnTici lo^is — Tho(li\erticula are the onlj ahnormaht\ seen
Their appearance in the first stage is the same as that in a birnim enema
After (i-acufilion the mucosal pattern is normal except for a corona of plica?
whicii occoj-ionalU surroiinds the ostium of the tliserticiiluin After iiifialiov
the (In crticula ina\ prc'cnt a vnnctv of appearances
1 llflr imflllc^lr nno I Inert cuK -IS ho in artcr an oj a jumtimU showing It «» tj^p cal
fliiok fll ail m
(1) Thorium filled and seen in profile
(2) Tlionuni filled and seen e» face The\ then appear as rounded opaque
shadows in the intcrmarginul 7<ne
ff) Air filic 1 and presenting an o|inque flocculcnt lining rhe\ then show
a tspical fla»k appearance
(4) Half filled with air half with thenum They then appear as dark
round opacities unless examined with tlio sul jeef erect when tfie> show a
fluid lc\el
(5) \ir filled and containing a concretion Three zones arc then riaihlc
the central concretion the clear nir space rr und it and the dark flocculcnt line
on tlio sutTOundiiu mucosa
J he nnuosa i f the colon itself h normal in appenmnee m dncrticulosis
Stcoi o» T)!\ 1 PTirt urrs — fie dirertimh appear exactly os alxivc dc
f>crils d ex(t pt tlial rctcntionof coiicivtioiisandbcvbala is much more common
DnLRTICUUm OF THE COLON
295
It IS in the inlencmn^ inMrt»«o that the changes mdicati\e of the inflam
matorj process apjiear The mucosal pattern is (lifficult to produce since
flocculation occurs iMth difficult as a result of the associated colitis This
also pre\ ents complete and e\cn collapse m the second stage of the examination
In the firet degree of associated pendiierticulitis the pattern is a little
distorted the plice fearer in number and rather thick As the inflammation
increases in degree those changes increase until virtuallj no phc-e are
Msible at all
The third stage of the examination — inflation — reveals the ngidit\ and
iiarroning of the aficefed segment and the opaque marginal line is thick
irregular and denticulated The intemiarginnl zone shows irregular opaque
plaques in place of the normal crazing
Tit colon distant from the affected segment commonlj shows changes — as a
rule increase in number and thickening of the phee This is a reflex reaction
in the musculans miicosaj — the clat trrilatif of Jilaingot
Tlie bowel generallj maj show considerable spasticitj again a reflex
from an inflamed area of dnerticnhtis This spasticity in a region remote
from the actual lesion mav give an indication as to the degree of the mflamma
tion and may often he seen to disap[>cAr as the acute focal inflammation
subsides
RADIOGRAPHIC CONTROL OF TREATMENT IN DIVERTICULITIS
Medical Treatment — Medical treatment is m the early stages prophalactie
and IS directed to keeping the stools semt liquid So long as staaia in the
dnerticula is presented the condition is innocuous The measures usually
advised are a diet w itli little residue and sufficient doses of liquid paraffin or
paraffin and agar agar to ensure that the slooU shall never be of a firmer
consistency than cream If paraffin docs not aj.ree mild aperients and salines
arc emplo\cd with the same object The efficacy of these measures mas be
tested quite simply by gising the jiatient a barium meal and taking radiograms
seven and twenty four hours after and sub'Kjquently os required If the
discrticula are clear as quickls ns the main colonic lumen the measures takci
are satisfncto^ If not a stneter regimen -sliould he adopted
Surgical Treatment — In some ndaanccd cases it is necessary to perform
coIo tomy itsunlly in the transverse portion Tins relicacs the condition
entirclv as lon^ as the colostoma is open the patient is quite safe closure
on the other hand is as.ociatcd with some risk of rcenide^cence of the di'^ose
In thc'^o cases after six to nine months the problem of closure of the
colostomy must be decided Bn then allmflammationwillhavesettlcddown
and further dclai nnolies ri«k of too marker! contracture of the I owel to allow
of ck ure
I barmm enema is an essential pn.ltminara to answering the followangj
quc‘'tiona
200
AI.r\lENrAR\ TRACT
(1) Is tlic inflinied segment too stenosed to allow closure of tlie coIo«tojuA
without resection of tlie stneture *
(2) If resection is neces&an, to penmt of closure is the hoiiel ahoie and
Iwlow the condemned segment sufliciciitK hettlth\ and is there enough cloth ’
to allow a satisfacton anastomosis t
riam closure of the storas without prcliminw re ection is po-^ible onlv
in a fen ease It is usuall> necessaij first to resect the stono ed segment
folloned a month or so later l>> closure of the trans^cr^e colostomi and again
n hanum enema e\amiiiation should be made of the sigmoid ninstomo«is before
the stoma is closed
CHAPTER XXV
THE RECrUAI AXD AXES
ANATOMY OF THE RECTUM
The Rrcnrsf consj",ts of that portion of the ahmentarj canal from the recto-
Mgmoulal jtinctioiv to the aiiua It is \anable in length the average being
4— C inches
It begins to the left of the inidlinc opposite the third sacral segment, and
runs down m the midhne m the hollow of the sacrum to a point I inch in front
of tlie tip of the cocejx where it joins the anal canal Vhen emptj and
collapsed it occupies the sagittal plane, and shows a curve with the concavit}
fon\ard8 similar to that of the sacrum The middle portion of the rectum is
ven distensible and is therefore sometimes called the ampulla Tins degree
of normal ilLstonsibilitj, is well seen in a bannm enema, or after a barium meal
m a case of d^skezia Vlicn distended, its lateral contours arc indented hy
the \alves of Houston
The %al\es of Houston are three in number, and are radiologicallj impor
tnnt since tliej- cause indentations m the rectal shadow Tlie^ are crescentic
folds of mucosa, each passing with a slight diagonal tdt round two tlurds of the
rectal circumference Tliej are inconstant m their position, but in general are
arranged in a tier e« echelon Lockhart Jilimtnerij has dc*cnl>ed tliem ns with
their free edges overlapping like a photographic diaphragm The uppermost
13 the most constant, and is situated anteriorly at the level of the peritoneal
reflection TJie lower two cause slight regular notches in the convex lateral
contours of the distended rectum The rectum ns it approaches the anus,
curves gently forwanU and fmallj turns abruptlj downwards and backwards
into tint canal
CARCINOMA OF THE RECTUM
It IS possiblj an overstatement to "ij that radiology ‘should plaj no part
m the examination of the rectum Even if it is bo, the statement ser\ es to em
phasisc that fingerstalls are cheap, and tint sigmoidos.copy is osimpleprocedure
If this •seems to labour the obvious the imtcrsexcu-^e is that on several occa
sions he has been requc>tcd to make a banum enema examination for suspected
carcinoma recti, Ixiforc even a digital examination has been made A barium
enema examination niav bo necessary to determine the comhtion of the
bowel liev ond the reach of the sigmoidoscope, or the degree of dilatation above
an alrtadv detected rectal growth, but to cmploj it to detect such a growth
ALTMEXTARY TRACT
it~elf IS not onl> «aate of an expensirc method, but is aI»o dangerous, since it
rnaj not demonstnite the lesion
With this caution it is permissible to consider nliat radiographic signs
maj }>e by cancer of the rectum dunng the course of an opaque
enema examination
The most constant change is diminution m size , the ampulla fads to dilate
to its normal contour, in
all but tile smallest growths
This IS the result of the
inelasticity of the infiltrated
portion of the rectal wall
(Fig 218)
If the growth is limited
to the posterior wall this
mav lie the only change m
tlie postero antenor Mew
Tiie rectum then gives a
“ jusio minor ” appearance,
ns the filling defect on the
posterior wall is masked b>
tlie barium in front of it
The semi Jateml anew ma.v
bnng the irregular defect
into view, but not with ccr
taint) If tlie grow-th is on
the Jafcrnl wTill the filling-
defect will stand out cJenrlj
im]e«3 innsKcd b) tlie sig
mold After evacuation of
the enema it ninj be possible to see tlic irregular contours of the grovrth coated
with baniira particular!) if some air be injected
SIMPLE STRICTURE OF THE RECTUM
'Hus if «?>cro, IS an exception to the almve rule Rndiologv mav lie an
c-c-ential step in estimating the extent and degree of tlie narrowing, if neither
finger nor proctoscojK. is aclmittcA
There are four c!assc*s of simple stneture — coiigcmtnl, traumatic, sjia-stic,
and inHammaforv
Till COMiiMTXL tvjx; commonK ocrur« at the nmco-cufnneou-> junction
of rectum and anal canal — the union of proctodeum and hindgut It nia)
var) from complete atresia to alight narrowing
Tn\i M KTit Stritm rr is n type hkcK to require radiographic imentigalion
and can rc«uU from a variclv of causes, among which may !»c mentioncfl
THE RECrrUJI AND ANUS
299
^ ounda, cicatnsation after Wutchead s operation for piles, accidental injection
of boiling or caustic enemata# and fibrosis folloinng radium irradiation of*
carcinoma recti
fepAssroDic Stricture is a rare disturbance of the neuro muscular mechan-
ism Although man}' authorities deny the existence of this condition, it has
been authenticated b} Lockhart Mummery
Post iNFL.ui'MATORi Fibrous Strictures, form the largest group This
IS a common «equeJa of septic proctitis The exciting cause may bo post
operative sepsis septic proctitis following dystocia, old gonococcal infection,
sjqiluhs, d} sentcrv , or bilharzia hicmatobia
It is not to be expected that X roy evanimation can do more than demon
strate the presence of the stncturc The cause must be determmed by the
anamnesis and clinical features of the case The X rav investigation is possible
onl} if the stricture vnU admit a rubber catheter , but tins it lisinlJj does If
a catheter will not pass, acute obstruction is close upon the patient
llic injection of the opaque solution should be closely watched under the
screen, and gentle pressure onl} should be used, since the bowel above the
stricture maj bo verj dilated and thin In addition, the colon above the
stricture should not be filled too full If distended, it may overlie and mask
the stenosed rectum Antcro posterior and both obhque radiograms should
bo taken to obtain as full a view of the narrowed passage as possible, and
stereoscopic news may be very Iielpful
The success of the treatment of rectal stricture, be it bj bougies, internal
proetotoma, proctoplastv, or excision, may obviously also be checked b>
X TA} oiamiiiation after an opaque injection
FISTULA IN ANO
Fistula m aiio i-s not ordinarilj a condition m which radiographic investiga
tion IS u«ed As a rule the surgeon is able to follow the course of the fistula
without difficult} b} other methods,
Occ isiomlly in cases m w Inch there is a deep seated and complicated
track, Its ramifications may be demonstrated m stereograms after the injection
of an ojiaque medium Either lipiodol or a sterile banum cream is a satis-
factor} medium The latter is to he preferred if tliere is difficult} iii retaining
tlie medium in the fistula, since its vascositj can easil} be increased
If the fistula 13 blind, it is usually eas} to fill the track complete!} , hut if
the track has an internal communication with the rectum this ma} not bo
possible A 8}Tinge with an olive tippctl cannula should he used It may he
possible to seal the mouth of the fistula with adhesive plaster, hut often the
ostium IS too deepiv placed in the natal cleft, and an attempt has to lie made
to occlude- it h} holding the olive ofthesjTingc against it during the exposure:,
A metal rectal bougie placed in the anal canal affonls a means of onentating
300
AI^TMEXTARY TRACT
the M'uali'tcd track in the ptcreogram>, Stercoscojn is e'csential and a routine
technique Biiould include filcreostopic antcro posterior ^ lew s and aho n lateral
CONGENITAL MALFORMATIONS
or the conpcnitnl malformations of the rectum and nmi*., some arc not
‘‘usocpfihle to radioprxphic demonstmtion, since the alimentary canal end**
blindly Iheoreticnlh , tuo could be demonstrated, although there appears
to bo no record of this having Iieen done Tor the sake of completeness they
might lie mentioned
(I) In Ihc male the rectum opening into the urethra just below the
utems miscuhmis by a narrow channel tlirough the prostate
(J) In the female the rectum opening into the navicular fo&sa of the
vnihnr cleft behind the vaginal onfice
Both these result from a persistence of the original commumcation with
the ciont i and are, accoitling to Clogg, the commonest forms of rectal
malformation
IlCFERi:XCES
\lvarez, B r. and iRErriLAMirR, B L.J Amtr Mot A$$,102i LNANIII
BakcLAY, A I, Tlio IJise«tirc Inot. Ixindon, 11)30
Bl.sNrTT T Iron, IIcmfp, I) and VAtciiAS, 3 M, Quart J V«l, 1032, WV
C03
Bi 1 0 , A , BontRcmiiitorrtUcliunj: am Inneiirolirf des \ erdauiingskniiab, ’ I cipsifr 1030
C^s^0^ W B , Atiier J TUiitiel , 1001-2 \ I 2>l
Case T T.Awrr J ; o<-«/-;rnflM020. X\l, 207
Cioor II \..Choiieei evatem of Surperv Ixnidon 1032, 11
( I ANf , A y\ , Amtr J I’otnltjtnul , 1027, W 11, -HO
Crons, B 11, Giszonic L , and Opprsin'iuci , 0 D,J Amtr Vffl .l»», 1032,
\CI\ 1121
Jascosi G,J)UrJ,r V(d IF/cAr, lOJO \I,M 10-18
Frrr 1\ A\ ,Jiril Vrd J, 1003.1 230
Oa^keli, "NA 11 , Tlu liiTOliiniarj Nenoits bjstcm, London, 1D20
Grt-DEUT, R , and Bauiamz L.J Jladial ritet, lf)3i .Will, 381
(.ooi.,L P.ArrA . 1011, X\1J 307
Gottiieisfi ^ ,Erglm Mtd Sfr«Af«t/(>MrA , 1028, 111, 425
r.nriQ, D lird J , lt)r> XXMl, 173
IIoDQsos H Guaiiav. /Var 7* Set- 1/nl . 1028, XXI, 1531
IIoiiissER, K Jtoalijfiipmiit, 1034, M, 677
IhuJKsrcuT G. Ifunch Jlul Tr»rAr,1000 lA 1.2401
llrr*7, A V,B/-il Ved J , 1023, 1, 145 , The Scnsilnlity of Uie ^lunnlftry Canal
Oxford, 1011
Jonr>AS,A C, CliroiiiP Intcutim! Stasis, Oxford. 1020
Kastoh.J L,J tmfr )ftJ cm. 2010, Jmrr J I oenlgtnol , lti2i All,
4U
KriTii, A . J Anat I'hijtioJ , 1003. XXXVIII, 7
Kikut, I’, • Rcornt AdvancrAin Badiolam, London, 1030
Krrjctis.II R . 7W J! Sot J/nf. 1934. XXMII. 519
Ksotue , • llip IhcktlarmskUlcimliaut,* Iciptig 1012
Lim., U i .aitd(.io«- R E.JwA 1934, A^MX. 3r5
THE RECTDJI AKD AJJUS
301
LAnMNhOia, G , iiull Soe Med J7<^ , raris, 1011, LXXXVI, 90
LocKitAET ‘MuJisrERT, J P , “ Disoases of the Rectum and Colon,” London, 1031
Locxhapt ‘Mumsiekt, J P , and Dowi'^n, H GiuiUJf, Srti Med J , 1031, 1, 523
LocirvvooK, C B , Bnt Med J , 18S2, II, B74
JiAisroT, G , SARA®I^, R , and DociiOS, II , “ TTploration radiologniue dcs colons et Ue
1 appondico au moycii dcs solutions lloculaiites, ' Pans, l'>35
Patet, U n , and Ascpoft, P B . Bnl Meil J , 1935, 11, 1 197
Q^JER^EAU, J , J/cm jlttjd CAir,i936 L\II 369
Ros5, j Patersov, and Telford, E D , Bni J Stirff , 1035, Will, 433
Pnell, A 'M , and Casip, J D , Arefc Jutern Jf«1 , 1934, LIII, 615
Spriggs r h,Vnt Med J . 1929, II, 669
Srpircs, E L, and Makxjf, O A, Qu/trl J Med, 1925, 2»JY, 2 , Bnl Med J , 2037,
II. 987
STErnts«ov, I B , Badiohgij, 1936, XVII, 49
Stiermn, E , ‘ XJnjischo Rontgendiagnoslik des Icnlanungskamla,” Beriin, 192S
Tiiatsen TEH, Baneel, 1929, 1, I0S6
PABT TWO
BILIARY TRACT
Br
PETKR KERLEY, MD, FRCP. DM RE
PAST TWO
BIL1\IIY HIACT
CH^VPTER XX\T
AN^rOMY AND PHASTOLOGY
The s\mptom vtoeoo\. of biliary tlise^ise is eomphc%ted and often misleading
Constitutional or local sj mptonis may predominate, and not infrequently the
local Bj mptoms arc referred to a healthy \ iscus farremovedfrom t lie bilnrj tract
The mtrothiction of cholecyetognplij has tIiro\ni considerable light on
the rctiologj course and aj mptomatologj of biliary disease, but there is still
much to be leanit and radiology is a most hopeful line of approach to out
standing problems A detailed knowledge of the anatomj and physiology of
the btliarj tract is essential if we are to carrj out a radiological examination
thoroughly and assess our findings accurately
ANATOMY OF THE EXTRAHEPATIC BILIARY TRACT
The normal gall bladder xarics m shape size and position according to the
habitus of the individual It also vanes according to the stage of filling or^con
tractioninwiiichitis visualised
and It alters considerably m
position wath changes in pos
turc Uougiily speaking wo
define tlirco normal tj jws — the
spheroidal or Iivperstiienic
type the ovoid orsthemctvqie,
and tlie elongated or hyrostlio
me 13310 riio ovoul or st heme
13 the ty pc most often seen
The normal gall bladder is
comjioied of four parts viz a
fundus a bodv, an mfundi
bulum and a neck Smooth
inusele fibres arc found in the
v\ all of the fundus and infundi
bulum but are almost com
pictelv ab'.ent m the hodv
Convcrsclv thorcisnmchclostic
\ B TI— 20
30^
300
BILIARY TRACT
tissue m the hod) and rclatnel) httle in the fundus and infundibulum The
mtistic fibres are arranged Jongitudinall) nncl obliquel) , but tend to lie circular
m the infundibulum Tim circular arrangemeut of the fibres is continued into
the neck and \ah ular part of the cystic duct and there is strong radiological
evidence in favour of a sphincter between the infundibulum and the neck
Tlie iietk of the gall bladder maj ho in the same avis as the fundus but
more often it tunis mwarda and downwards at a fairlj sharp angle The
c)stic duct usuall) arises at an angle from the neck but this angle vanes
ton«idcrabl) according to the tj^ie of gall bladder and the stage of
its contraction The proximal half of the cjstic duct contains circular
muscle fibres and the mtenor is tlirovvn into folds known as Heisters
valves TJie distal half of the cjstic duct is similar to the hepatic and common
](ilc ducts m that it contains few muscle fibres if anv, and is simpl) a fibro
elastic tube The common bile-duct runs downwards parallel to the spine,
and usuallv passes through the pancreas before entering the duodenum obbquel)
at the papilla of Inter The volume of the normal gall bladder is about
10 e c but no bniits can be fixed for its fength and width
RADIOLOGICAL APPEARANCES OF THE
VISUALISED CALL-BLADDER
The Ovoid or Sthenic Gait-bladder
(A) InF Prose Postnov — (The appearance of the contrortmg gall bladder
and bile ducts ns descrilicd lelou can lio noted onl) if the technique of serial
radiogriiphv immcdiatel) after a fatt) meal js followed Bv the ordinarj
hnplwnul teclimque the ducts ate rarcl) Tiswahsed ) The gallbladder
IS ovoid or pear shaped about D to 10 cm long and about 3 to 4 cm wade Its
long axis is parallel to tbe spine and at nght angles to the eleventh and twelfth
ribs, Tbe liver margin «een ns an oblique hue running dowaiwnrds and out
wards usualls ctits across llic gall bladder shadow at the level of the bodj
This corresponds with tlic usual anatomical description the fundus of the gall
bladder l>eing free and eompletel) Biirrouiidcil b) peritoneum and the bod),
mfumlibiibim and neck being fix«l in the hepatic fos.sn b) eouncctvvc tissue
Tlie gill bladilcr lies well forwaid of the kidnev but radiologicnll) the two
fllmtlotts are aujKrimpfVstd In most cases the gnil bladder is superimposed on
the upper poll of the kidnev but it nia) l*e suj)erinij>o«tfl on the renal pelvj«
or it iwaj lie metbal or peripheral to the kidnev shadow Anatomicallv of
course there is no relatu nshiji Iitlwceii the gall bladder and the right kidiic),
and the jiositioii ami range of movement of Iioth organs ma) var) considerabl)
in tbe one individual liio Tadudogieal relatimiship is mtimato and of much
importance l>etnii-e of the possibilitv of the sliadowa of hiharv iniculi lx*ing
superimposed on the renal sliadow and vico versa
If a Imrmm me il is given it will be round that the fundus of tlie gall
b!nd<Ieris usiiaKv mapjxisitianvnththcduoiloiial rap wliiih is Ivangumneshatcl)
AYATOMY iiND PHYSIOLOGY
307
bohiml the fundus In some cases the gall bladder lies cH to the right of the
duodenal cap and in other eases it lies to the left of the cap and ma^ be in
contact uith the pjlonc part of the stomach
In about 2 1 per cent of normal individuals part of the gall bladder shadow
IS superimposed on the shadow of the second and third lumbar \ertebra.
(B) Tiic Euect PosmON — Both hver and gall Madder are about I to 1 inch
lower and he below the shadow of the twelfth nb Their rehtiie relation
ship Js unaltered but if the
gall bladder has been lying
partly over the spine m the
prone position it tends to
fall awaj from it m the erect
]>osition In the erect
position also the gall bladder
shadow lies more to the right
of the renal shadow The
relationship with the duo
denum is unaltered
(C) In the SuitNE Post
TiON the hver and gall
iiladdor fall back and up
wards The long n\is of the
gall bladder becomes oblupie
instead of pcrpeiidiciilar and
thefundusmav lie comploiolt
bclundthelow crliv er margin
Ihe gall bladder lies well
uwaj fiom the spine audits
shadow 13 above or barelj
touches (he shadow of the
upper jwle of tlie rjj,ht
kidney The gall bladder
di'ftwAfw.?! rctatKmstiifr /<■ n&t
nllcrc.l In tho BUpiTlP IWl „ Tl. ..omnl ovo U»>1 1 taller m n tio
tion the pear shape is lost proto po tion
and the upper part of the
gall bhddtr the infuiidibuluin is rnundccl and almost as wide as the fundiis
OccasjonaDv iii this position a slight or deep indentation niaj be seen in the
medial w all of the gall bladder Tins indentation rojirc^onts the point of di\i«ion
lietweon the liodv and infundibulum and it sbould not be nnstal cn for spasm
1 he neck of the gall hladdor the cvstic duct and the common bile-duct can
liovHuah cd onlv during the pbisc of active movement follow uiga fittv meal
In most eases a sharp mdtntation on cither «ule sepamtes the neck from the
BILIARY TRACT
30 «?
mfundibuluni and at certain stages the neck nia} apiienr to l>e completely
separate from theinfmidibiihim this is fairly coiiclusne c\ idcnce tint there is a
strongsplimcterlieti'eeiitheneckandtheinfuiulibiilnm Tlienccl it‘ielfma\ bo
filnpcil like the pointed end of a jwncil and run straight upu ard'» but more often
It cur\e3 inwards and has lioeii aptly de»cribcd as resembling a birds heal
Tlie ctstic duct usiiallv lca\ea the neck to curve gonth upwards and in
wards for ibout | to 1 inch it then forms a complete semicircle and joins the
common bile duct but the point of junction cannot be Msuahsed Occa ion
ally the cvstic duct leaves the neck at riglit angles aYid in some cases the neck
13 bo l>cnt over on the infimdibuliim tint the cvstic duct appears to be leavnng
the mfundihiilum at right angle-^ This appeiranco is very unusual but abould
not be mistaken for pathologv (adhesions) TJie proMraal half of the cystic
duct lontnming inu-itle fibres and Heistcra valves has a cimous appearanre
due to tlifi mivture of hilc and mucus Small round globules of concentrated
bile appear to lie lying between the imieosal fohls and this results in a ros.iry
liead appearance lliN occurs m 7o per cent of cases and has occasionally
been nnsinterjirclcd as stonoa m the cystic iluct
The distal half of the cystic duct and the common bile-duct are seen as a
smooth narrow tulie with no irrcgulinties of outimo at any part theshado'v
of the hilc in these parts is only about half the density of the shadow m the
gall bladder and m tiie muscular part of the cystic duct Tlve lower end of the
common bilc duct usually fades away into the spinal shadow and its point of
entry into tlic pincreas cannot be seen
The Spheroidal or Hypersthenic Gall bladder
In stockv or short olwse individuals and m moat children the gall bladder
tends to be more rounded and to be lucd more completely in the hepatic fossa
In Fomc (nscs the whole of the gall bladder is actualiv cmlieddcd jii iepatic
tissue It is then Fccn ruliologically as a completely round opacity It
follows that the iiiolihty of the hypersthenic gall bladder is limited and its
range of muv cment is deiKuident on the range of niov ement of the liver w Inch
is blight The Jiv-persthcnic gil! bladder is situated relntivelv high and iisuatlv
lies under the tenth or eleventh nh It is Mtuafed well to the left of the spmc
and well aliove ll o right kulncy shadow Barely as descnlied by \enioiirs
Aiijnsfe a fivivcrstfienio gaff bfaihfer is actiiaffv supcrimiKjscif on the spriirfi’
shallow In some cases tlie hypersthenic gall bladcler has the ovoid sliapo of
the sthenu tvpo Us lon„ avis is then parallel to the lower margin of the hver
niul i> almcst at rn,ht an„les to the slmdovv of the spme
riic neck and ducts arc motv difficult to visualise in the hvptrsthcnic tvpo
The neck is onlv occisionallv seen and may npjicnr to Iks the most ilepcndcnt
part of the gill bladder In most i ises of thu> tvjx; there is no \ isihlc clifTircn
tiaticn Isctwcen the neck and tnfundthulum ami the cvstio duct seems to arise
dircctlv from the lowest jnrt ofthegill bladder
, oill pnll blftilcler aimnq llio phaxa of airtivo conlractiOH Tlio cystic nml common ilncta aro clearly
\ isiblo : noto how ihe rmled cyetio Juct teiuls to unrold.
I (.all I ta I Irr 1 nn^ le|Ia>i f»
A^ATOAn. AND PHYSIOLOGY
311
The Long or Hyposthenic Gall-bladder
This type occurs in tall slender indindua!» and is characterised by a very
uide range of mo\ement The fundus and body are completed free and
co%ered by peritoneum and the neck and mfnndibulum arc attached to the
h\er b\ la\ connects e tissue In the prone and erect positions the gall
bladder is seen to be panllel to the
spme and in \ery many cases the
>\ hole of the slmdou is Rupenmpoacd
on tlic spinal shadon and may thus
l>e o\erIooked The fundus of the
gall hlfidder mav bo ns low as the
level of tl c fifth Innibir vertebra in
the prone position and niny be level
with or lower than the lower pole of
the right kidney One gets the ini
pression in these cases that the gall
bladder is ptosed and iticfficient
This IS invariably an erroneous im
pression for if the caammation is
properly completed and the gall
bladder observed in its active phase
It vs ill be found to contract ansi
evacuate its contents normallv The
jw ition of the gall bladder has
nothing at all to do vsath its tone and
there is no reliable recortl of a pitlio
logical pto-jis of the gall bladder
The neck and ducts are easily
visualised in the hyposthenic gall
bladder and arc similar in j osition and appeamnee to those seen in the sthenic
type There arc of course many intermediate tyTics between tJie tliree just
dc'senbed and tl e above classification should lie taken onlv as a rough guide
TffE Fcrvcrrapf or the gall-bladder
The liver IS constantly secreting a thin watery bile v\hich flows into tlic bile
ducts and m tlie ducts is dilutcil bv the addition of mucus Tins bile enters
the gall bladder by flovnng up the cystic duct provided the sphincter of
Oddi is closed (Aminaa) Tho gall bladder concentrates this bile and when
the pressure m tho gall bladder falls below that m the bile ducts more watery
bile runs in llus process continues until the gall bladder i-s full of concen
troted bile According to licictmn tlio sphincter of Oddi then relaxes and
liver bile dnp'> steadily into the duodenum
The concentration of the bile in the gall bladder i-s carried out chiefly hy
Pia 3 Tl <* I onnnl »] beru lal or
1 c gall bU n r
312
BILIARY TRACT
absorption of A\ntcr Bihnibm is concentrated about tMentj’ times, and chole-
sterol, bile salts, and talcuim about fnc to ten times Calcium is excreted into the
bile by the h^ erand partly absorbed and partlj concentrated by tlie gall-bladder.
It IS non generallj agreed that the gall bladder does not secrete cholesterol
Tina process of concentration can, to a certam extent, be confirmed and
studied by cholcc\«tograpliy An hour or two after injection of «odium
tctmiodophcnolphthalem, a faint gall bladder shado^^ can be seen , from two
to SIX hours after the injection the intensity of the shadow increases, but the
size of tlie gall bladder diminishes It follows, from tliese obsersatioiis that
at different times the gall bladder contains bile of different specific gruMtics,
one layer, so to speak, floating on top of another This theory explains the
increased density* of the shadow when the gall bladder has partially evacuated
its contents after a fatty meal During the eiacuation the bile of low specific
gravity and gall bladder mucus are cxpellerl first and the bile of highest
si«cific gra^ jty remains behind Wielher the theory of multiple layers of bile
and mucus is correct or not, particular attention should liejiaid to the question
of different densities in the one gall bladder There arc on increasing number
of reports of floating gall stones ic small stones floating on top of concentrated
l)vle, and it wcins hkely that with routine hospital technuiuo the«e stonw are
being oterlooked and the gall bladders passed as normal
The Mechanism of Emptying of the GaINbladder
Tlierc Is still considcmble disagreement as to the exact method by which the
bilo Icaies the gall bladder, and it lia-s caen been suggested that the bilo was
roabsorliod in tlie gall bladder and that Ifeisters aahes were Xaturcs deiice
to preterit the bile flowing back from the gall blailder into the cystu duct
It lias Ijcen clearly estabhalicd by Wfftphnl and other* that the tagui. is
the motor nerte of the gall bladder — hght ragus stimulation causing the gall
blarlder to contract and the 'splumlcr of Oddi to relax with simultaneous
jienstalsis of the ampulla and a flow of bilc into the duodenum Strong ' agiLs
stimulation causes sinsm of the gall bladder and ampulla and ce>sation of
flow Syiiijiafbctic stimulation causes the gall bladder and ampulla to relax,
with smmitaiieous contraction of the sphincter of Oddi and no flow As
ytirwnn points out, there is obrjoiisly a reciprocal innciaalion There is a
Immoral ineiham«m in addition to the nerrous mechanism, the normal gaU
blachlor reacting at once to injections of cholecystokimn, a sub-tance which is
jUTKlticcd b\ the action of acid on the niu<?osa of the duodenum and jejunum
There IS probably some cholccystokinin fanned also in the stomach
The normal pliy Miologicnl stimulus to the ei aciiation of the contents of the
gall blailder is the presence of fat m the atomneh and duodenum There is a
sliglit jwy chic reflex, taste and smell causing the gall bladder to alter its it'sting
IKKsitioii and adopt what we shall refer to as the “preparatory' position
Taste and smell, howexer, will not cause the gall bladder to contract
AVATOMY AND PHYSIOLOGl
313
Attgusie has sho^^n that this ' bucco \esicat reflex’ can be stimulated re
peatocllj ^iitliout anj evacuation of the biharj contents The same author
has shown bj miving his fats writh banum that the gall bladder m man>
normal cases begins to evacuate before the pvlonis has opened i e before am
fat has touched the duodenal walls
In studying the gall bladder nuliologicaUj' we should see it m three phases
(1) The resting phase mth the gall bladder flaccid and concentrated bile
in the fundus and bodj
(2) The preparatory phase whieli can be excited bj smell or taste or observ ed
immednteU after ingestion of tbo fattj meal In this phase the gall bladder,
so to speak pulls, itself together It altera its shape so that concentrated bile
appears to bo evenly distnbuted in the whole of it and the infundibulum and
neck arc vi‘'ible It alters its position at the same time the general tendency
being to move upwards and outwards The range of movement of the gall
bladder m the preparaton phase vanes of course wuth the tvpe of gall bladder
In the hyposthemc gall bladder a considerable shift takes place while in the
lij'pcrsthenic type little or no alteration m position occurs
(3) The phase of coidrachoH is observed after ingestion of a fattj meal at
intervals varying in the normal from five to thirty minutes In the contrac
tion phase the gall bladder is m the same position ns the preparatorj phase
but its volume is smaller and concentrated bile is visible in the cj stic and com
moil ducts TIte normal times for completo evacuation of the gall bladder
have not jet beencstabhshcrl Boyden bosshovni that the gall bladder empties
more rapidlj in women than in men and it is probable that tliero is quicker
evacuation in children than in adults
There 18 no doubt whatever that tbo gall bladder empties its contents bj
imi'icular contraction although the nature of these contractions must lie totallj
difftrent from those vv Inch occur in the gastro intestinal tract True peristalsis
has nov or been observ ed and there arc onlj one or two records of a wavj outline
of the gall bladder in anj waj suggestive of pcnstalsis It is possible that an
ovenhstended gall bladder ma> cmplj bv clastic recoil but «enal radiograms of
the normal gall bladder during tlie contraction phase do not suggest tint elastic
recoil plajTs anv pvrtinthcaveragocaj^ Insoroo normal causes the gall bladder
certainlj rotates from side to side the author having observed tlie neck first
pointing to the penpherv and htcri>ointing to the spine Both the neck and the
cjstic duct tend to straighten themselves out as the bilois forced into them It
has l)cen proved that the normal gall bladder cannot l»e emptied bj vohmtarj
movements respiration nor diicKlcnal pcnstalsw Radiological observations
have also showTi that vomiting does not cans© it to contract In two p<atients
one vnth hjpcrthvroubsm and one with hypertension the author observed the
gall bladder contracting under pressure from a compressor but although there
was no organic biharv disease m cither patient, their general nervous instabilitj
was such that none of their nseem could be considered TW'rfprtlv nnrmni
CH^VPTER WVll
TI-CHXIQUI I OR MU'i E\AJIIJ»ATIOX OF THE BILIARl TRACT
PRELIMINARY PREPARATION
Tul rvmvT must Ije a<!cquatel> prepared by suitable aperients or enemita
I tees and gas m the intestines can obscure the gall bladder completely or
pnxlui-o shadows simulating gall stones Drastic aperients such as (astor oil
and in'\gne>'ium sulphate cannot be recommended as tiieir action may irritate
both the gastro intestinal and biliary tracts for some dais Cascaro is very
suitable as its action is mild and it does not (end to evcito gas formation In
jiatients iiith obstinate constipation an enema is necc'>sary and tins should be
giien at least SI hours before the X. ray examination Persistent gas forma
tion despite the effect of aperients and onemata may cause great difficult)
both m technique and interpretation Many drugs ha\c been u«ed in an effort
to ctixjl intostnial gas and the most effectivo of these is a substance knoini m
plt^e^ in This substance is administered subcutancou'ly 0 5 cc being
injected from one to tuo liours before the \ ray exainmation The dose can
be rciieatod inthout any harmful elTects in half an liour Pitrcssm is eminently
suitable m difllcuU gall bladder caws as it does not cause the gall bladder to
contract
ROUTINE OF EXAMINATION
In all case*’ a prclimuiary radiogram on a IS x 12 film should lie made
Ihis film taken m the prone jxisition should include the domes of the dia
phnigm and the crests of the lilt It should shnu the low tr In cr margin the
kidnee shidows and the eilgc of the proas muscles A Potter Buck) dia
plin^m is tsjiential to ensure good detail nml the finer the grid the Iretfcr the
results The Eyshom stationary gnd is not aery suitable because the grid
lines nia\ oliscurc imi»ortant iletoil Tlic most important feature jn the tech
tuque as hjk'cUi and cacrythmg elw should be subordinated to thu Ihe
fihgUtcbt respirattiry movement ma\ lie flufficicnt to cause enough blurring to
conceal gall stones The pitienl should l>c made os comfortable as pfjssible
and the exposure made at the end of expiration An ideal speed and one well
w ithm the limits of most mmlern apparatus is two fifths to one half a second
The author u>*i*s this spectl with (ho following factors 90 Ala 7^-80 kA
00 ems tulie film distance Svmchroniscsl moxing gnd
If the prrbmmarx rubogmm shows indisputable ta idenco of gall stones it
nm\ not lie necessary to carry the examination farther butgcneralK speaking
It IS a vi«e procedure to make a thorough examination bt cholecystography,
314
XRAY EXAMINATION OF THE BILIARY TR\Cr
315
ns this mi\ revenl unsuspected pathology m the ducts When the gall
bladder has been made visible bj sodium tetriiodophenol^lhalein films are
taken vnth the technique described above In-a fair percentage of cases the
first picture mil shou some part of tlie shadon overlapping the spinal sliadou
Using a ball of cotton wool an a compres*»or it is easy to displace the gall
bladder away from the spme — this roanomvre will not cause the gall bladder
to contract and the shallow can be adequately studied on this second picture
V third picture should bo taken in the erect position mtli light compression
W ith modem methods of cholecystography and a good fluoroscopic screen it
IS not diflicnlb to visunli-ic the gall bladder on the screen when it has already
been located on tlie prone pictures Only light compression should bo applied
as tlio object of this inetliodisto reveal floating stones and strong compression
may force such stones into the conccnlrateil bile at the fundus M hen tlie«e
pictures bav o been taken the patient is given a fatty meal consisting of two or
three eggs heaten up wnth milk (7uOmnn and Xemours Avr/tisfe add some
barium sulphate to this meal and simultaneoiLsIv with the gall bladder study
the gastric and duodenal mucosa A picture is taken in the prone po'^ition
immediately tins meal is ingested and usually shows the gall bladder to have
changed from the resting to the preparatory phase Five to ten minutes after
ingestion of the meal two further pictures are taken in the prone position one
central and one ^hghtly oblique vnth the right side of the body rotated about
15 to 20 degrees away from tho table i e to the left TJie cotton wool com
pressor is used for these and it is aino helpful to tilt tlie patient head dowTi
wauls about 10 to la ilcgrccs In 80 per cent of cases the cvstic and common
ducts will bo visible on these pictures If not similar pictures are taken twenty
and thirty minutes after the fatty meal until tho ducts have been visualised
$!iljsequcnt pictures are taken an Jioiu* after the fatty meal and t)n»c usually
show tho gall bladder to be contracted to one third or one fourth of its original
sire
This technique niav «eeni tooeloborate andcvpensive but it is tiioonly one
by wluohthebiliarv tract can be thoroughly investigated and as will be showai
later it throws much light on those obscure cases of biliary dyskinesia where
there is an npparentlv normal gall bladder shadow associated watli classical
chnRaJ symptoms of gall bladder distension
CHOLECYSTOGRAPHY
It was long knovni by pliyviologisis that the halogens were cvereted almost
cntirch by the liver in the bile and tetrachlorphenolpbtbalcm was froquenth
used as a test of liver function (7raAam and Cole in l'J24 applied tlus know
ledge to radiology, and attempted to visualise the gallbladder tji ino bv
substituting the heaner bromine molecule for tho chlonno one Their results
were successful and in a very short period the still heav ler iodine molecule was
substituted for the bromine the loiline comx>ound giv irif' a shAflmi \nfli
31G
BILIARY TRACT
a smaller (lo!>c The substance m common use to daj is the acid sodium salt
of tetraiotlophenolplithalem It detenorates rnpidlj on exposure to light and
should be kept m opaque bottles Tlio tlrug shouhl bo freshly prepare<l for
intravenous injection llie drug can be ailniitiistered intravenously or orally,
and although most uorkcr* now employ the oral method as being simpler and
lexs dangerous than the intra\enou-» mctho<l there me nian\ cases in ■which the
intra\cnous method is preferable If on intravenous injection was an
ab'iolutch harmless procedure it would obviouslj be the method of clioice as
a miasurcd quautitj of dje va injected into the blood-stream and it can be
excreted onlv througli the Inhan tract Using the oral method there is
nlwavs the jKiastbilit} that the d>c mil be unabsorbed m tlio inteutmc or that
the phonolphthalein will excite iharrhoea vnth rapid excretion of much of the
lodme through the bowel There la u group of c-ases m which the concentra
tion of dje in the gall bladder is poor and onlv a faint radiological sliadow is
obtained The interpretation of faint shadows is much more reliable with the
intravenous than with the oral method
Technique for the Intravenous Method
The patient on the evening before the injection has a liberal dinner,
including fats Hie injection is given carl> the following morning weak tea
witli sugar but without milk Itcmg allowed for breakfast Ihc dje which
should bo prepared the evening licforc is wamiotl to body temporatnro and
injected slowlj ‘'ome workers inject J ec of 1 in 1 000 adrenalin sub
ciitaneoitslv before the intravenous injection but this is unnecessarv and
indeed in some cases mav produce unpleasant fcnsations of natieea and fainting
Tlie syringes used for Ibc dvc sbouhl be thorougbl^ tienned in atenlo water
jtirticuhr care Inuig taken tlmt there is no oilv or greasy Btibstanco on tlio
walls Tor an average individual -I grins of scMlitim tetraiodophenolphthnlcin
disBolveil ill -JO i ( of distilled water are u*-ed lor thin individuals and
cluldrcn half this quaulitv i* used \s the djo is blue black m (olour it is
almost imjM)<wible to see blootl flow back into the svTinge and it is iisii illv
eisier to place the iiecillo iii (be vein and then attach the svnngc wlicn the
nccillc IS safe!} in jwsition The dve should lie injected verv slowlv a safe
rate licing 4 c o per minute 1 here should lie no pain dunng the mjc c tion and
the jMlient should lie kejit under observation for half an hour nftenrards
After tins period he can currv on with liis usual work The lin.t jucture is
taken four hours and the second picture eight hours after the injection file
maximum concentration is usu ill^ at eight hours and at this time the cxamina
tion IS completed b) observing the efTcrts of the fattv meal
Contrfttudieatwiif to the intravenous mcthoil arc advanced cardiac and
pulmonarv di-caHC asthenia or cachexia and severe jaundic-o ITic dangers
of intravenous cliolccvstogniplij are greatly exaggerated /'nedand W/iilaUf
have shown cxi^mncntailv tlvat the hver mav Iw. more than half fattv
\ R\Y F\AMINATIO\ OF THE BILIARl TRACT
317
degenerated and jet excrete the dje normaUj' ^nthout an\ trouble Accidents
follomng the injection may lx? due to one of three causes (1) An impure
solution has been used ^2) An erccssne dose Ins been injected There hare
been tuo fatal accidents follomng injection of 5 a grms and one following the
ingestion of 5 grms In these three ca«es lionet er autopsv shoned extonsno
h\er disease (3) The dje has )>een injected too rpuckly Too rapid injection
19 much the commonest cause of accidents In some people a curious and un
explained tram of symptoms follous the rapid injection into the blood stream
of nnj substance of high atomic weight Half to one hour after injection tlie
patient complains of cold and shivering and tliere is marked trembling of the
limbs In severe cases there is pain bclnnd the eyes and pains in the bones
Amounting and fainting con also occur and in xerj bad cases tlie patient maj
collap«e into a Jjnd of coma Alanj workers have shown tint there is i rapid
fall in blood pressure inimedmtelj after the injection this might cause collapse
in a patient with heart dii>case but is iinli! elj to be responsible for the syinp
toms of pain and trembling of the lindia ZnppnJa has sho^m that foUovnng
injection of tetraiodophcnolphthalcm there is a hj poglj caimm after half m
hour a hj perglj cccinn after two hours and then a gradual return to the
normal values m six hours Hv'pogljc'cmia is a very likely cause of the
svmptoms just described and manj workere use glucoso along with the dje
to prevent the onset of such symptoms In most cases the injection of ^ c c
of nilronahii gives prompt relief but proiided lhat the vijectton ti gnen sloiily
there 18 no need to use either gluco«e or adrenahn as a prchmmaryprophv lactic
There appears to be a general impression that leakage of the dje from the
vein into the soft tissues is a serious incident This is not so and I have
observed many cases where such leakage had occurred and no untoward effects
other than tcraporarj stiffness of the arm ensued Of course infection is nlwaj s
liable to occur if the dje or the instruments have not been sterilised In
rare cases a severe non bacterial cellulitis or a mild phlebitis inaj occur
Rapid Cholecystography
Alany workers have attempted to combine the sodium tctraiodophenol
phtlmlcin with some other sul stance which is rapidly excreted through the liver
therclj obtaining more rapid visualisation of the gall bladder The method
which has attained most prominence is timt described bj An^om/cct It was
carU recognised that during cither oral or intravenous cholecystograplij in
di ibetios the shadow of the gall bladder apiieared much sooner than in normal
individuals lidoaiicri « technuine is Imscd on this observation The patient
has a diet poor m carbohydrates for three or four days licfore the injection
T1 0 injection is made fasting under the conditions already described Ten
minutes before tl e injection of the opaque salt I2o c c of a 40 per cent
solution of glucose are injected Ten minutes after the injection of the opaque
salt 2 > units of insulin are injected Tlie gall bladder ea i be faintly seen half
31S
IlILIARY TRACT
nn hour htcr and the nia\inmm concentration is obtained about two hours
later The contractions of the gall bladder and the Msuahsation of the ducts
arc then obtained by the usual fattj roeal The physiological basis of this
technique i» not projierlj understood it is thought that the tetraiodophenol
phthaicin 13 combined in some manner with the gluco‘«e and that the ooinbina
tion is more rcadiK escreteil through the luer than the opaque salt b} itself
It lna^ lie however that in hj’pcrgUcrmia the hver is stimulated and more
rapidly eliminates the opaque salt The gal! bladder filled bj this rapid
method is larger than the gall bladder fille<l by the usual method and more
oyer the concentration uith A«/o«i/fCitf technique is not very good It is
doubtful if anj material ndyantap* is gamed bj Antonucas technique and
certain!} none yvhich outweighs the ilisadrantages of injecting three diflerent
suhatanecs at yen short intcrrals
The Oral Methods of Cholec>stography
If sodium tetnuodophcnolphthalein is ingested in a pure fonii nausea and
yomiting usual!} foUoyr m a short peno<l of time This is due to the salt
mixing vnth the gastnc secretion ami forming plitlnllic acid uhich is a distinct
gastric irritant In the carl} days of oral cholecyslograpb} the salt yvas
usuall} admmistcrc<l in gelatine or kerntm capsules uhich it uas Jioped
Mould not bo digested until they had left the stomach In many cases Iiom
ercr the enp.>ulos Mere not disiiolyed at all and were excreted intact with tlio
f'ccx‘8 The manufatturers hayc largely overcome tius difiicult} andthed}e
IS noyy made up m a fairly palatable form yntli (be phthallic acid alread}
precipitated About Jo per cent of patients complain of nau‘-ea after ingts
lionofthedye and of these about 6 per cent actual!} yomit Jftbe yomitmg
otcurs vnlhm one hour of mgcstion the test is invalid as too much of the dye
IS lost If the yoiniting occurs within two hours of ingestion the test is ustinlK
y iilul ns in tins time sufliicicnt <l}c has pn^swl ox cr tlie p} lonis to lie absorbed
in the small intestine *v)mc yvorkers give various sedatiye drugs gii h as
Dovtr s powder to prevent vomiting hut thendmmistralioii of kucIi Bul»tnntes
is to 1)0 dcprecattd In the present state of our kmovvledge of the phssiologv
of the biliary tract it is imjHi^siblo to predict the cfTcct of man} sucb drugs
They ina} cause delay m filling or empt}mg or poor concentration
Single dose Oral Cholec}‘stograpfv}
T1 c follow ing simple prejwrition is the onl} one necessar} and is successful
m the vast maj nty of cases Two days lieforc the examination the patient
takes a mild aixnenl «.a«cara for pteferenct. The day liofore the exaramatton
the jhitieiit has a meal containing fats and eggs for lunch and for dinner at
“pin has a fat free nual ^Inn\ tn^hshMorken do not consider complete fat
rest notion es-scntnl I or elmircr dry tovst linkc 1 jvotatoes \ogc table soiips
and all forms of fniit are allowed Jniit dnnks and black tea or rofTfc nro
X RA'V E\AiII^ATIO^ OF THE BILIARY TRACT
319
also permissible Butter eggs milk cream fish meat and salad dressings are
not allowed At 9 p m 4 gmis of the opaque salt are mixed with half a
tumbler of abater and sualIoa\ed in one draught \\ atcr maj be taken freelj
after this and I ha\e found alkaline waters such as Vichj and Vittel \erv
effectiae m reducing the degree of nausea and the possibility of vomiting
The patient may liaae weak black tea or colfee on the morning of the
exammation but no sohds The \ ray examination is carried out at 1 1 a m
1 e 14 hours after ingestion of the d\e If there is no shadow or only a faint
shadow visible at this penod a soft picture of the abdomen la taken to see if
there la much imabsorbed dye in the mlcstines If there is a further 4 grms
of dve are gi\cn to the patient to be taken with a fat free lunch A fat free
dinner is allowed and he returns fasting the following morning
Intensive Oral Cholecystography
There are many sanations of the intensive or double dose oral method
In moat people the single administration of 4 grms in one do e gises a good
concentration and this method has the great advantage of simplicity JIany
workers follow modiDcations of a technique devised by Siewirt and IlhcL
and gi\e small quantities of the dyeoacra penod of two or three days during
winch period tJie patient must lire on a completoh fat free diet Tins is a
complicated procedure and unsuitable in many patients whose ideas of fats
and non fats aco peculiar Recently II hUnUr has shoim that the gall bladder
IS completely full of concentrated bile in 24 hours and therefore there is no
point m ndmimstenng the dyeoa era longer penod than this as it does not add
to the concentration **
T/je auOiors technique js simple for the patient and usually gives a siiffi
crently good concentration for the gall bladder to I e visualised on the screen
yvith a compressor Tlie day before the examination the patient has a
normal luncli not fat free and immediately after this meal takes 2 grms of
the dye U 7 p ni the patient has a fat free dinner and takes 4 grms of the
dye an hour after this Dunng the eacning a bottle of alkaline water I's drunk
and the patient ’presents hira«clf for the examination between 10 and 11 a m
Awsvrayy^ ? Av jWsiWP pw'Xvt.ywv advisw Ji giswvJ
filiadow one further picture is taken m llie erect position a meal of three cgps
in milk and a teaspoonful of sheny is given and further picture?, taken 5 10
and 30 minutes aftcMngestion of llm fatty meal The complete examination
takes about an hour In some cases the goll bladder contracts scry slowly
and an hour and a half to throe hours may be required to obtain all the necessary
data
CIi*\PTER wyill
hlE r-VTIIOLOGICAL BILIARY TRAC'I
CONGENITAL MALFORMATIONS
V sTCD\ of conipintue anntomj rc\<nK extreme ilovelopniental ^nnatjona
of tlie biliarj tract in nrumala Unis tlic horse and tlio rat Jm\e no gall
bladder while the cow and the mouse ha\c The pigeon is the onl> hinl with
out a gall blaildcr but it has one during fcctal life Ont would expect to find
the IvuiuRU bibara tract hliownng inanx developmental nbnoTninlvties but this
dm s not appear to be the case Hoyden in 19 000 autop les found five eases
of double gall bladder with a single cystic duct \ rst re/wrts of rJoiiblo gall
bladder are ^c^^ nre Hraiinschueuj has descnlicd such a case, uitli the
shadoiv-B of tlic two gall bladders suiwiimiJoscd in the jwstcro anterior %ipw
O ne concentrated tlie d>o mutli better than the other Obliritie mows after
H fittj meal showed the two gallbladders contracting well and King well
cliar of each other The ducts were not verj clearly visililc Imt his pictures
suggest that there was a separate c>*stic duct for each vesicle A bifid gall
bladder is aUo hnoun a lougitudmal septum dividing tiit gall bladder into
two sepinK sections Harluny has demonstrated rndiologicdly a verj
unusual anotnalv the gall bladder att iclieil to the left lobe of tho liver liar
tung s pictures show a normal gall bladder lying on tlie left side of tlie spinal
shadow parallel to the lesser curvature of the btomach Complete ahsenco
of the gill bladder has aUo been dc>cnbed in man this defect is usually but
not alwavs accompanied bv gross dilatation of the eonunon duct
The most frequent coiigciiitnl anoninK seen on radiograms is a beptum
extending across the fiindns Tins bcplum niav lx* minute or it niav almost
div ide tlie fundus into two scjiarntr chambers In the average case tbert is a
deep mdeutation on the fundus rather «wmdar to an mciaura on the greater
curvature of the stomach aiul the gall bladder assumes a shape aptl> described
ns ri'scmbling a Phrvgmn cap riiisdcforniit} is probablv of no clinical sigmfi
<anre altliough stum workorslxihcvoit inav pre(!isj*o«e to gall-stone formation
Flnil lias described vinous defonnitjcs of the bile ducts and of tlie right
hepitu ovstio ami gistro duodenal iirtenes There mav for example bon
double tvstic <lm.t and a single common duct or then mav lie a single cystic
duel and two tommou duels Tlic implantation of the cvutic duct into the
roiumon dint mav aKo take an abnormal course 1 cw of thtoo abnormalities
liavc liceii licteited nidiolocicnllj prolmblj liecausp tho function of the gdl-
llidder and the visinlivation of the ducts have not lioon investigated ns a
322
BILIARY TR\CT
roiitiDc With modem teclimqiie,
however it is to be expected that
more radiological reports of thc«e
anomalies Mill l>e dcscnlwd m the
near future V niro congenital
abnomnlitv is obliteration of the
bile duets Such cases of k terns
neonatorum do not Ii\l icr\ long
and ob\ioiis1^ the abnormahti can
not lie detected bj cholec\stof»rapli\
CHOLECYSTITIS
Cholecxstitis niaj be iiditc or
chronic There art manj sarietics
and degrees of intcnsitx
The acute 1)76 ma% be catarrhal
supjiurat i\ e iilcemtn e phlegmon
ous or gangrenous but irresjicitjve
of the txpe cholccjstograpli^ is
contraindKated m all acute cases
The dje mn\ nggrointe the tnflim
mation and m am cose there is
iKiund to be failure to concentrate it \ plain nuliogmm of the gall bladder
region max be helpful bx rexealing opaque calcnlj
Chronic cholecystitis nny follow the ncutc fonn or the dteevse iim he
chrome from tlie fir*t It max lie jnrt of chronic catarrh of the ducts and it
mij or max not l>e nsaotmted with gallstones The chronicallx inflamed
gall Madder is usually distendcil with mutus its walls are thickened ami its
mucosa is thrown into hoax X folds Rarelx thcgall bladder l>ccoines shnxelicd
up and small {cholccy^tihs oWi/<’mns) In <*i.«es where the cystic duct is
blocked by a stone the gall bladder becomes permanently distended its walls
ntropln and excntuallx become a tlim rbeet of fibrous tissue like parchment
The xisibilitx of the <1x1 in thcgall bladder is cntirelx dependent on the i>owtr
of the gall bladder to ci)mx?ntrate If therefore we find complete ab tntx of
a shadow after projKr technique tin dxc lias cither not reached the pall bladder
iv'fWA'se A-Wfiwr.Xv.xv rt/ ?A\? da<^ <jc (fiv rfye A’W feacfiwl
bladder but the muco.sa is so cxtcnsnelx damaged that it eaiiuot eoncentrate
it In cither ease thi gall bladder is a surgical one It has Ixtii snggcsttsl
that non xasinlisation occurs in (he hUratapes of prtgnaiicx due to pres>ure
recent work has not siilntantinteel this suggestion Not much is knowm nlxnit
the eficct of cxtonsixe lixer <liM?ase on the coiiccntmtion of bile m the gal!
Mulder II hiltilrr found in dogs xxitli extensixe liver il iina^i a norma! cun
cciumtion of the dy< in the pall Mailder but clinical exiKricnce does not
THE PATHOLOGICAL BILIARY TRACI'
323
altogether support this idea TIio efiFect of any acute abdominal condition
on the metlianK-s of the biliary system js impossible to estimate, but the
consideration is of no importance, ns cholecystography is contraindicated
m such cases It can be stated ^iitliont reser\ation that complete non
Msuahsation indicates a gross lesion of the biliary tract and is an inchcition
for surgery
Mild Chronic Cholecystitis — Wc must discuss now these cases of nuld
cholecystitis ^\hlch constitute the greatest radiological problem The so-
called lipoid choleoyttitis {strawberry gall bladder — cholcsterosis) is CTtiemely
tommon MacCarUj found 030 cases of this disease in 5,000 excised gall
bladders lioUeston and il/cA*ec summarise the pathology as follows “ From
lymphatic obstruction the tilli Iieeome loaded with cholestercd absorbed from
the gall bladder bile Extenially the gall bladder is normal except for an
enlaigcd gland near the cystic duet , internally the papillsj appear as yellow
streaks from contained cholesterol-ester, and so lesernblc stiunberr^ seeds,
they break off, and so may form the nucleus of future calculi” Neuman
does not consider the condition worthy to be elevated to the position of a
iliseisc although Moynifuin once described it as a “disease of the gall-
bladder requiring cholecystectomy ” Newman's opinion would appear to
l>e that the condition is a nuld inflammatory process consequent on a
mild infection of tiie gall bladder, but that possibly it may be due to metabolic
or dyskinetio causes Ihe evidence in favour of the latter causes is so far
inadequate
Rndiologically therefore we are faced with a condition which we know to be
common and w hich, even w hen trii lal, must lieosaociated u ith some disturbance
of the biliary function In a cholecys>tograplncexnmination wc see three points
by which we can estimate the biliary function {!) the rate of filling of the
gall bladder , (2) the capability of the gall bladder mucosa to concentrate the
bile ns evidenced hv the intensity of the elindow , (3) the rate of emptying of
the gall bladder
(J ) Tiih Rate of Freuvo of the Gaix oladder — It is olivioiw that the
rate of filling. i e the rate of appearance of a shadow , can never be estimated
accurately by the oral method and indeed this is a strong argument m favour
of using the intravenous method in the “doubtful” cases Following a
projierly administered intravenous inycclion of the dye, a faint but obvious
shadow should he seen four hours Inter, and the shadow increases in intensity
for another four hours This avenge rate of apjxjarance of the shadow lias
Iktii proved, and if we add as a liberal margin anotlier two Jioiirs as being
within the normal limits we can state that if there is no shadow visible after
si\ hours there is disturbance of the function of the hver or gill bladder or
both Bearing in irnml that cxj>enmciils on animals with artificially damaged
livers do not show much delay m the rate of appearance of the shadow , and that
in most cases whali wc cvnniuie it is safe to assume that there is no gross liver
324
BILTAUy TRACI
it follows that delat in the rate of filling is due to disturbance of the
gallhliddcr itself In mow howoter of Cullman 8 work on tlic frequenev
of sub acute necro-^is of the liver the possihihtv of the liver being at fiult
should not l>c cntirclv excluded
(2) Till. IvTFxsm oi Tin Shadow — Unfortunately wo have no standard
oritcrion by whicli we can measure the intensity of the shadow &omo workcra
wmijiare tlic shadow of the gall bladder with the shadow of a transvene pro
cc«s and others use the Kidney or InerBlmdows as a standard TJicmj criteria
are too unrtlnhlo for general purpo^s ond the estimation of the intensitv of
the shadow must alwavs be a personal one There can be no possible doubt
of a vtrv faint shadow — it mean'* cither that the gall bladder is full of mutus
or that Its nnuosa is suniciently damaged to prevent normal concentration
What one mav term a poor sliadow h one of the most diffieiilt problems set
to the radiologist It is impossible to dogmatise on this question and perhaps
the wisest course is not to ilmgnose patliologv in tbese cases on the intensitv
of the shadow (done although statistics for the Mayo Clmic show that the
jvoorh filling gall bladder is pathological m approximately 9i> per cent of cases
'Ihiru H wnclusivo evidence that a strawlierry gall bladder may give a shadow
of normal intensitv
(3) flip Ratl 01 EitiTtrsQ oFTiit fiVLi ULADDER — There IS a Conflict of
opinion on this ipicstion some worlers lieheving that the strawberry gall
bladder empties too quickly and others that it empties too slow ly the majontv
licmg of tlic latter opinion Wc can ontv estimate the value of this sign if the
pKiimination is e.imcd on until the gnil bladder is completely emptied It is
not safe to osAiimc that if the gall btaihler contracts down to half its volume
rtflcrafattv meal tlieelnstnity ofitsw ilN is intact There are many cases in
which the gall blaihlcr mal es out vigorous contraction nflor a fatly meal and
tin n relap'<'s into a comlition of otonv with stagnation of the residual hile for
a lone IK-tk d '^emnun Aujiisfe who has mvestigatid this i»rohlcm verv
thoroughly thinks that in females the iinrnial pill bladder should lie coinplefclj
emptied III an In ur after « fatlv meal and iii malts in an hour and a half Any
longer jktuhI ho considers to In ev idence of disturl nice of the hiliarv fiiii< tioii
The e standards are rather st\<rc niid most workers would prefer a longer
porio 1 sa\ three hours \moMr-« Ii/jniHc also i.trea es the appLarnnee of the
<l\t in lilt gill 1 ladder m the usual prone position If there is conctntratcil
dv( onlv at the fundus and if the intiiisitv of the slmdow diininislies pro
Lrvssivelv fnww Ivclow ujiwanls he roiiMders then, is wme pathology present
rills sngn IS of douhtfiil value as m a nonnal gall lila Ider there may he ns
inii<h as 2u < i of iinnus seirtfcd and fliating on top of concentrated hilt
In these mild cases of choktystitis tie clmicat and \ ray findings must l)t
<arpfu!lv loireliteil If a thorough exaimnatu n has !>een made and the gall
hla hfer fills si jwIv empties rIowIv an 1 gives a ahndow of weak intensitv it
IS safe if» diignoH c! oleovstitis
THE PATHOLOGICAL BILIARY TRACT
3>5
GALL-STONES
G^Il stones are compo«etl m \ir>ing proi»ortioiis of chok^terol bile pig
jiients aixl calciiini salts There are probablj nnnj factors e^'-entia! for the
formation of stones bnt the most important ones arc infection and hilnr\
stasis CholestemL is the
doimnanf tiemcnt in the
niajontj of gall stones ami
this IS a substance non
opaque to X rajs In nniu
cases hoa\c\er there is cither
a fentraJ dense niiclens oi
hihnibin calcium is laid down
in thin laj ers o\ er the chole
sterol Direct Msuah&ation
of gall stones is dependent
on the quantity of bile pig
ment and calcium salts
present In the pro cholec}'&
tography era skilful workers
tstimated that thei could
Msuahse about 40 jicr cent
oi gall stones but this pro
portion e\cn with modern
technique is much too higli
and 1(J per c-ent would be a
fair estimate Stones com
posed almost entirely of
cholesterol can sometimes be
\ isuah«ed as so called iiega
ti\c shadows but this
diagnosis unsupported bj t’*® — Lttmuiatc<letons»ir» tt opals bla Her emlont
limleCTt.fOgnnIn is nO\t!r m '!«• «J-'« Oral cbolj jrto-r,, l„ ,l,o« ,
I 1 » concentmtfon ftom 1 ciirjni rhj« < Cii
more than a possibility as
there are so many possible causes of negative shadows m radiography of the
right In'pochondntim
Occasumnll^ gall stones are ►ecu which nin^ bo comjHi-'CcJ of about ^10 ixir
cent of calcium carlionate and 10 per cent of cholesterol Tlie«e stones are of
two types white and green The while ones are soft, and associated with
obstruction of the cjstic duct , the green ones contain copper in addition to
calcimn carlionato and are associated with some general nietabohcdisturbancc
Call stones are usually multiple and \ary m sire from a gram of sand to a
florin nie smaller the stones the greater the miinher pre
32G
BlUUiY TR\C1
moncNt Iiiinmn gall Mom l** the faceted stone lliis is compn‘'ed of -v small
rniiml central nucleus purroumled successive Jijcrs of cholesterol crvstals
Ijvycrs of protein and bihnibm calcium arc Kid doim here and there hetucen
the cholesterol and those render the stones radio-opacjue On a radiogram
this tv’jH, of stone is inoderateh opaque has a clear centre a dense jienpherv
and a pnhgoml or faceted outline Wlicii the gall bladder is paekeil nifli
there 8t( lies if has a mosaic apiHarancc Round stones arc less common and
leml to !«. larger Ihe round Mono has a translucent centre and an outer
liver of bilinibm calcium whidi
nppcirsasa w hiterin„ The < aloium
mav not siirnuiml the uholt of tiie
Mone and onh a fine reiimireultr
or sickle slinped lav er of calcium mi\
lie viMble The round stone vanes
iiiuvli in size but is seldom smaller
than a pea and maj be as lug as a
Horiii 'IiiItipIepuiKtifomi oitanties
the so called bilt sand arc not veia
frequent but oreensa to diagnose ns
there IS no other enus© (orojiaeitiesof
thistv|K. in the right livpocliundnum
^e^^ rarch one sees a stone uith a
dense caleifiisl nucleus and a non
ojiaqiie cbolcsftrol both tlic latter
visible as a negative shadovv round
the dense nucleas The cnleiiim
inrlionntc Mones are rare fhev an
iisualh single ami n>und or barrel
Hhapcil
Differential Diagnosis — («all
stones mnv lie confii'sjtl vvilh renal
stones cakified glamK calcifical
costal cartilages intrahepatic calcifi
cations pancreatic calculi and suprmnal calcification*
Utml gtoim and gull stones are not infrequently present together \s a
rule nnal stones art denser larger and more imgulnr in outline than gall
stones but occasionaUv gall btoiies ver> bimilar to renal Rtevnes occur The
dilTcrcntial diagnosis can lx* made directiv bv taking pictures in different
phases of rt*spinition nml in different postures The gall bladder 1ms n wider
range ofmorcmeiit during resjuration thin the kidnev In the prone position
a gall stone mav be sui>ernni)«i8ed immtxhatelv over the renal |ielvi.s but if the
patient turns about 30 degrees to the lift i© with tin nglit side of the Ixidv
tilted iipnanls and the left sielt m contact with the Potter I5uck> (ho renal
THE PATHOLOGICAL BILTAR\ TRACT
327
and gall bladder shadow s are sepanted and a biliarj opacitj is jirojected ui
front of the kidney In the true lateral position a gall stone is seen anterior
to the spine and a renal stone w 6upenmpo’»ed on the spine In the supine
position a gall stone nioaes upwards and outwards wlule a renal stone mam
tarns its position relatn e to the spiml column Rarth renal stones lying in a
large hjdro or pjo nephrotic sac can lie differentiated from gill stones onU
hj carrjing out a pyelography orcholceja>tographs
CVi/cij?fd glands m tlie abdomen arc presumed to be of tuberculous origin
T uberciilo is of the glands m the porta Iiepatis is almost iinknow n and generally
speaking it is un
usual to find calci
fied glands in the
right hypochon
<l r 1 u m Most
abdominal calcifieil
glands arc m the
mesenten andhaac
a coiisidcmhle range
ofmoiemoiit liie
demonstration of
this wide range of
moyoincnt b\ coni
pression is often a
simple and cffcctisc
mctiindofdiagnosis
The calcification m
glands is aery often
granular a form of
calcificationnotbcen
in gall stones In
ilouhtful cases, a
cliolccy stographe
M\5*
Calcififd cMtal cartilages var\ cnormousU in shape and sue Roteden
has shown that they are often convex downwards ami thus they may
simulate the nnj or semilunar type of gall •atones The respiratory mo\enicnt
of the coital cartilages is so chamctenstic and so different from the rc^piratorr
movement of gall stones that difficulty m diagnosis can only anse with poor
tcchnn^no
I ntrafiepatic calculi are rare are ususlh multiple and are distribute^! over
such a wide area that they cannot possibh be m the gall bladder They are
composed almost entirelv of calcium carlionate and are much denser than the
av erago gall stone Calci Jied hyda(fd ejfsfs in tlie hv er and calnfed liter abscesses
Fig “ 9 — F (cbolwlenn) galJ nlw es shown b> orel
cholcc^Titograpl V
328
BIUAIIV THA('r
slioM dcH-^ perjplieral niie-}
of calcnmi, aiul ilo not
change their rchitne jxisi
tions in the supine am!
prone positions Tlieso calci
ficntions arc not often con
fused with gill stones but
ina\ simulate calcifnalions of
the gnll bladder itself
Pniimotie cnlcnlv are
dcri=e9tones composed almost
entirvlj of ealcium carbonate
Tilt} an? nut? and nsunlH
nmltiplc with the gn?!!!^
ntimlxjr l>ing m the left
hj jiochondnuin \ gohtnn
pancreatic calculus jii one of
llio larger iwnercalic ducts
has an oval shnjie rather like
a uretcnc calculus
Jiupraro al r/i/rijictifion
rare but mat lie similar
to gall storif s \ tholccj*sto
graphv Is the best method of
iiiaktr g this difTcrcntial dmgtiosts although it can Ix^ done bv picttm*s m dificr
ent jXjstnres and di/Terent phases «»f rciapimtion \ calcified nnenrism of
the renal arten simulating a gall stone lias lieen descnlicfl
Cho!ec>9tograph) and Calbstones
In about jU jht tent of ta-Ks ot gallstones no -hatlciu is obtained bj^
cholecastograplia flus is «|ue (itlior to n stone blocking the cystic duct or
to the pall bl idder imussa |»eing h» thniogtxl that it cannot eoiuentrate the
<he Tilt caact diagnosis is not of great intuiicnt as the complete nb';ence
of a shadow calls for snrgital treatment
In aljotit 30 {xr « nf of cjisr* the gall blatidcr shadow is famtU visible anti the
sttines art t Icarlv v i«ible in it Non opKpK stones are «ecn a** round or faectctl
areas of trarishirt tiev If there nro inanv of these stones tlie diagnosis h
easv if there arc onlv a ftw tlic diagnosis raav be verv difiitnlt ns gas
shadows m the dutKierium anti colon cause verv similar ai>]>earamed Oblique
views and views ni tliffc rent jmsliires vvitli ccjiiipression inav aolvc the problem
but the niowt cfifcttivc method w to romplttc the examination ami studv the
gall blnilder after a futtv meal When the gall bladder is eontraeted Bloiies
nhilo filiil remaining utsule its >-h>ilovv alter their position and are iisuallv
IHE PAlHOLOGICx\L BILIARY TR-VCT
32 »
forced dowi to the fundus In the erect XKJSitjon stones usmlK, but not
nlwnj's full doun fo the fundus
In about 10 per cent of eases the gall bladder eoncentrutes the d^o nor
inallv and the stones are \ isihlc in it The method of differentiating the stones
from gus shadows is the same ns m the previous paragraph It is sometimes
< un I (6) »l o ^ tic MiTinf fp » mniform a low cast b> tl « t>U Mer nt a inontli s mtonal
(c) iH the eNcb-cii gall 1 la I Ur No concentrat tii otuirc*! with tiitca^idcii oral cliolocj stocraphj
trrontouslj stated that if there is normal concentration of the <I\o with
stones the gall bladder is functioning normally and the stones are sunpl}
foreign bodies tloing no hann It cannot he ovcr-eiuphasi'.ed that the degree
of conccntmtion of the d\o is no index of the proper function of the galj
bladder — it simply means that there is enough healthy mucosa left to con
centrate The rnto of emptjmg of the gall bladder wi
330
BILTARl TRACT
ahra\i 3 blou taking often thr«i or four ]iour« to evacuate completely This
means that there h considcrablo of the walb* nml is an indication for
ssiirpical tnatment
In nlioiit 1(1 per cent of ca‘.c^ a gall hhdder containing cholesterol stones
concentrate?. th« dye normalU ami the concentrateti dye conceals the stones
complcteK Tlie first pictures are those of a normal gall hlailder but during
(t/' %.
•r k-
!• I -S’* —A aw of cl ron c cni
filo« cl The Urge
rouft 1 ojwc fv ts «au«e<i 1 v cal ora
■ orl>onale Min i in ll e fun lu< tin*
^inall ocie 1 1 a (ulc um rarbonatt*
»lone m t) c cj-kI c il ict \ chI ifinl
"Ian I u prrsrfn t boinn No ««n
central on onrormi w tli oral choU*
c\»iogr*jh\ sni analj iv of 11 c
contents of 11 t gall *,!• I ler eacwwt
a few b\-* later no trace
of icira tfwio 1 1 cnolj htWc n
tilt phiLttcs of contraction tlio atones often repeal themsches ns translucent
sliaduns and then, is delay in o\aiintion I'\eitthcn ho\ve%er such stones
may l>c in^'isihle nitli routine technique Asalread\ rnentionetl somoofthc«e
amall ctilciili liase a lo'fir specific gravity than concentrated hilc and float
In interesting papers tltirger anti Jfratl^ford show how the«o calculi can be
demonstrated in tlic erect position In gentle pressure with a compnssor In the
erect position the concaitratetl bile falls to the liottom of the gall bladder
and with gentle pressurt- tin. stones ran be seen a-s small translucent shadows
hing hnnr.ontalb nl»o\e this The pictures should Ire taken with varviDg
degrees of prc*s.siire It is obvious that strong pres.stire will either force such
stones up into the gall hladtlcr mucus or down into the concentrated bile
THE PATH0L0GK3AL BILIARl TRACT
331
Fio coh u n carbonate f times Visible through a gas d ten Ini he{>at c
flexure in tho ohi que \ ew
<iuct itself Is o^al in shajie like n ureteric or jiancreatic calculus Tho dif
ferential diagnosis from a ureteric caIcuIus is eisd^ made Itj a choleeysto
graphj or a pj elograpltj but it proie imjwssiblo to distinguish betncen
« ixincreitic and a common duct calculus
CALCIFICATION OF THE WALLS OF THE GALL BLADDER
Tills H a rare occurrence It cannot occur without extensive pre-existing
fibn)si‘« and js tlicrefore a sequel to a ebronic cholecx'stitis In the continental
text books it IS dcscnlied as the porcelain gall I ladder The diagnosis is easj
and tho calcifiwl walls are clearlj xisible on plain radiograms The calcium
is hid down sxmmttnealU and the usual ovoid outline of the gall bladder is
33
334
BILIARY TRACI
M«iblo It IS that a catrificfl gall bladtlcr of the round or stlicnic t\'pe
%\ould gl\e an -ipjwarance idenlienl with a calcified livdatid c\st Cliolecpto
g^'lpll^ Mill difTtreiitiatc these two conditions n normal gallbladder filling
taking place in the ea'-o ofhvdatid disease At a clmieal meeting of the Ilnfish
tio .1' 0]uu{i>st<iO(tc<l«ini ‘aiitli pimil I la 1 i r duct lui Illieroiiunou luct Th>>
far tr«I apo of il c etunrs in ll <• lu 1-4 fthon< ilut »n crated l> ri» from tl i. pnll t In i irr
Institute of Rujiolop^ a case was sliown in winch two 'f n large gall •atones of
the Ting t>}-ic Bimnlalcd takdiration of the wills Tlic difTercnUal diagnosis
IS not of iinportanee as liotli comlitionsaniKiiigical Ihe cakificd gall bhdder
cither Miinpictch f uls to concentrate dtt or concentmtes it fecblv oinl slow!)
THE NO\-CALCIFIED
GAhb-BLADDER VISIBLE WITHOUT CHOLECYSTOGRAPHY
Otin^ionnlh a well-d(finc<l jmll bli Idcr alia low is M'>ihk on a prchmimn
radinemni It has the nsnal ««\iiid B!in«e and cm l>c tlcirh distingiiishetl
THE PATHOLOGICAL BILIARY TRACT
33a
from the liver and kidnej
shadows This appearance
Ins been recognised and dis
cussed for main jears but
we are still uncertain as to
whether it represents disease
in the gall bladder or not
Kvox was of the opinion that
it was normal and be was
supported liy man> workers
in Europe Alost American
workers arc inclined to the
view that spontaneous \isi
bilitj of the gall bladder is
pathological Ifwe consider
tile factors responsible for
radiological Msibihty of an
organ it is remarkable tint
the normal gall bladder is not
been more often Calcium is
excreto<l into the bile by the
li\ cr in relatiN tl) large quan
titles LiNcr bile, according
to ^euMian, contains 00 mg
of calcium per 100 c cm of
bile and tins is further con
Fjo "33 —Calcificaljon of tJ «> ^a]! bla 1 Ipr
centrated in the gall bladder
Altbougli CaniwH was of the opinion that
gall bladder bdo was no more opaque than
lucrbile his experiments wore not vabd ami
there IS no doubt at all but that gall bladder
bile must be more opaque The quantit\
of calcium in normal gall bladder bile is \ er\
often much pvater than the quantitj in gall
stones which can be clearly Msualised Mana
workers ascribe the nsibihtj of the gall
bladder to a grcatl> increased concentration
of the bilo whioli is described as gall bladder
mud lliLs tlieorj will not fit in with clinical
or ph^slologlcal facts H ktlaler has shown
exiicrimentalh that the gall bladder cease:,
to conc-ontmte after tnenfj four hours fo
that CNCn if there is stagnation for longer
3^0
B1LI\R\ TRACT
tlnnthis jwnod the<lcn‘='»t% of the bile remains the same although it ma\ Iwl
blacker and thicker to the e\c It i> an mterestmg fact that much fewer report
of spontaneous iisibihti of the gall bl'idderhaienppearcdsincetheintroducti r
of thoIet\»tograph_j It la ob\ioii3 that the onlr certain method of (.heckin
thebilnn function is In cboleesstogniphy and this should lie done in all thc-s
ca cs The radiological diagnosis of gall bladder mud should be discanled
BILIARY DYSKINESIA
The neuro inu«!eular mechanism of the gall bladder and ducts has alrcid?
been dcs( rihcd in the chapter on the normal Disturbances of this mechanisir
are not infrequent and causeBtTnptomsacfj difficult to dtstinguish from s^Tiip
toms of otganit disease The possibiht> of functional disturbance bem
responsible for gall bladder ^lain was long ausjiccted but it is onl> m recent
sears Uiat the question has b^n adequately explored ^ cicmon ^ Ooulstonian
lecture^ giie an admirable and etliaustirc suncy of the chmcal problem'
miolied It his been shown that ovcmction of the vagas tau>es spasm of the
gall bladder and ampulla and cessation of tlic Pou of the bile uhile stimula
turn of the sampatiietic cau-ses relaxation of the gallbladder and ampulla
with contraction t f the sphincter of Oddi and again no flow of bile The
former condition cau'Cs spastic lUstcnsion and the latter causes atonit dis
tension of the gall bladder The syonptoms in both ca.«es aro the same i e
gall 1 ladder pain It is ob% ions tJiat m both conditions bile w ill flow normallr
into the gall bladder and wall be concontratcxl there but m tioth ea^es there
will lie diaturhunce of the rale of emptying and probabK dilatation of the
common duct N evvinn s lectures were, debs ered before it was realised that the
<hicts could Ik? m uah'icd m most eases He descniics the cholceya*togm/diic
npjieaniu-e- of «p<iAfio distension ns follows ‘TJiere is nn opaque well fiUci!
well-conccntntm^gall blidder winch diminislie-'afterthe fatty meal but docs
not di apjwar and which shows a delay m emptynng In atonic di5tca«ion
oholccsutograiiha shows a sera long (Inn gall bladder which throws a poor
shallow oml rniptics a ory little Sptistic di-tension H associated w ith a li\q»er
tonic btomach and In’peracidits while ntoiuc distension is associated with a
low atonic stomach and hvpjaeidita In both forms of the condition the
common duct mas be dilated and nltUwigh the subject has Iiecu practtcalK
unexplorcfl ba radiology (herr are a fess reconN bx /troiiner ami \emoitr^
liju*te showing such dilatation Morcoxer \einonr9 Au(;iffe has demon
•■tmted regurgitation into the jnira hepatic ihicts and there is no doubt but
that the o«JV5ioml reports of Imnuin flowing into the ducts is tlui to «ome
sh'tutbamx of the neviro muscular nieshanism In the case ilUistroted in
I ig there is tlcarlx a spasm jii the inidillc of the cxstic duct Tins t\pe
-ofdrskmcsia docs not apjicar to liairo lieen de“cnbcd liefore Now that wenm
demonstrate the ducts tiie radiologic il diagnosis of 1 iliarx dx'skinc'ia is com
joaratixclx easx nn 1 choice xntographr will at last throw light on thev-e oli^cure
33S
IJILlAm IRACl
cases where there is definite chmcal evidence of gall bladder pun with a normal
concentration of the dje m the gallbladder There arc nianj degrees and
\unetic3 of biliary dj'skinesja — to appreciate these and their possible effect
on cholecj stogrnplu appearances the cliniuil picture should be studied m
Xevimm* work
PERICHOLECYSTITIS (ADHESIONS)
In most cases iKjncholecvstitia is a sequel to or a complication of cliole
t}8titis Pro\ided the gall bladder can coiiccntnvte the d^e such adhesions
can be demonstmted If the gall bladder in the prone position is parallel to
the lower border of the bier adhesions lictuccn the fundus and tlie li\or arc
jirobable and if the same lelitionship is mRmtaine<i in the erect iwition
adhesions are certain /iron wer has demonstrated adhesions between the neck
and tlic common duet with a ragged outline of the duct showing during the
phase of contraction Adhesions to tlio duodenal tap and second part of the
duodenum ire not uncommon \ gall bladder impression on the cap is not
necessanli pathological but if tins appearance persists and if the tap ss
irregular in outline there aic probably adhesions present Adhesions to the
second part of the duodenum displace the laiwcl upwards and to tlio right and
in some ta-es tenting of the outer w all of the bowel is visible Occasionally nn
adhesion nins across the common and castic ducts and preaents the ejstic
duct unfolding when the gall bladder contracts rather like a string being tied
around a loop of hose pipe and preventing it unfolding when the pressure of
water enters John Iluuler in a (icrsonal (ommunicntion stales that he has
seen three or four cases of this nature at operation There were typical
svmptoins of gall bladder ilistension with a normal cholecystograpln and at
o|)cralion the gall bladder was normal The obstnicthe aymptoms were
entirely due to the small adhesion Hal IhcbC casts been investigated b>
modern technique marked tlclay in emptying would have Iwen found Ocri
Kionnllv an abiionnal iKntouenl told the evsto duodenal or cysto colir li„i
ment takes this course across tlio comiium and cystic duets and it is p<)s,sih|p
that this ligament might cause similar partial biliary obstruction The qiics
tion 13 of some imiwrtaiice as it is going to prove very difficult to distinguish
lietwctn dvakimsia ami distension due to adhesions or ahnomial ligaments
Adhesions betwteii an milamed gall bladder and the hepatic flexure are not
uncommon Sutli adl csioiis are nearly nlwavs associated with tvpical gall
bladder pain and a eholecvstogrophy reveals a pathological gall hlailder
Rarelv tenting upwanls of the upper lionlerof the proximal end of tlietmn®
V erse colon is v isible Tliero are occasional reports in the literature of cholety sto
colomo fistulfc Startz and Medtbnan have described tvpical (a-ses of this
nature rccentiv The patient complains of diarrhcea with a historv of sudden
onset of tlie diarrhoea The stotls are frothy and brown to clay colours!
nicre IS some loss of wciglit and discomfort in the rip,lit livpochondriiim In
THE PATHOLOGICAL BILIARY TR-\.Crr
339
both of the author s cases a banuin enema passed jiorjualh round to tJje hepatic
llexxire and then filled tlie gall bladder and the biharj and hepatic ducts
Perforation into the small intestine does not apxieir to be so frequent A
barium meal nill not neoessanlj flon from the duodenum into the gall bladder
m such cases, and the meal niaj gi\6 no clue to the causation of the symptoms
Occasionally a large gall stone passes into the small intestine through such a
^J« 241 — .‘n’kth] t (CHX of the duodcmit c«p «lionMig a Uuotleno 1 /i'iUjJa TJw gflJJ
bliuldcr r< (UIcl wilh bantnn
fistula anil r'au^cs acute or sub acute intestinal obstruction Tlie author
examined a case of this nature and found one large stone clearly \U3ible in the
gall bladder Althougli the history strongly suggested that another stone had
licen nipturetl into the small bowel, this stone could not be \i«uah«ed, and a
meal ga\e no help other than the demonstration of distended coils of the small
mtestmo At ojieration a stone about the size ofasfulimg was found impacted
in the ileum Xot infrequently a gall stone attack causes symptoms of
340
IJILTAR\ IRACT
intestinal obstniction «itJiout am possa^ of stones into the bowel The
diagnosis of siicJi cases is most difficult — if a baniim enema re%oals no patJiologj
in the large bowel following an attack of apparent intestinal obstruction the
radiologist should make a lareful examination of the gall bladder area Rareh
gall stones rupture into the anterior abdominal wall The author examined
one ca-vc of this nature The patient was an elderly woman complaining of
abdominal pain and nausea with alight loss of weight Clinical examination
mealed a large haul mobile mass in the region of the hepatic flexure A banum
meal showed no abnominhtj of the gastro intestinal tract hut there were three
large gall stones of the ring t)'|)e in the region of the palpable tumour An
oral cliolecjstograph} ga\e a toinplctel_j negative result At operation tiie
three laigc stones were found emliwhlcd in the antenor abdominal wall and the
gall bladder wmtninod several small non op(U\ue stones
TUMOURS OF THE GALL-BLADDER
^^e arc indebted to hxrllin for our knowledge of the \ rav appearances of
neoplasms of tlie gall bladder Small jHtpiUomns are the most frequent
riiese give charictcnstic appearances
Tliey are seen as small translucent
defects »suall> on tiic lateral walls of
the gall bladder Their avenge size la
about I cm and tliev are not larger than
I cm The> are multiple and two or
three apjicar to be about the average
numlier presrnt The gall bladder m
most cases concentrates the dye well
Ilie ilofects always maintam the same
relative jiosition in the gall bladder
iirespeclive of changes in posture or
phases of contraction The appearance
in the Idled gall bladder resembles fetoim
or small pockets of duodenal gas Stones
hiwcver alter tlieir jio-ition during the
contraction of the gall hladder and duo
deiial gas can usuallv lie eliminated bv
pressure or changes in posture
AdcKomn of the gall bladder is a rare
tiiiiiour It occurs most often m the
fundus and appears os a singlo small
itcmicirculnr or circular translucent de
feet m tlie fuiidus of a well fillcsl gill bladder An adenoma h best visualised
when the gall bladder has coivtrutod down and evacuated almut half of its
c-ontenfs Like ikipillomas an adenoma never alters its |>o-,i(iofi
THE PATHOLOGiaAL BaiARY TRACT
341
Primary carctnovia of the gaH*bIadder is not common Statistics show that
in most cases carcinoma develops m a gall bladder eontammg stones Chole-
cystography has not niatenallj n^^isted m the diagnosis of cancer In most
cases there is n completely negative 61ling, in some cases stones may be ^ isible,
without, however, anj clue to thepresenceof a growth, and in one case Kirilin
found a normal concentration of the dje Taltrla has reported one case in
which there was a filling defect of the outer wall and an indentation of the inner
wall
Tumours of the. Lih-ducis are rare The author, in one case of pnmarj
carcinoma of the hepatic duct, found a complete failure of concentration
POST-OPERATIVE VISUALISATION OF THE BILIARY TRACT
This procedure has attracted more attention m America and the Contment
than in England Tlie object of the evaminalion is to determine the pitency
of the common duct and the efficiency of drainage after choledochostomj It
IS often ver^ tbfficult to palpate small stones in the common duct at operation
Lipiodol, or «orae similar substance such as brommol, is slowly injected through
the drainage tube into the ducts under the screen Tlie reader is referred to a
paper by Hujford for details of the technique It is imperative that the in
jeetion be made slowly and under the screen, as, if some of the opaque material
IS forced into the duct of Wirsung, it may precipitate rcdema of the pancreas or
acute Inrinoirhagic pancreatitis When the opaque material has been in-
jected pictures are made at intervals of fifteen minutes, and the patency of tlio
common duct checked h} the appearance of the hpiodol in the duodenum
The calibre of the common duct and the time taken for the flow of hpiodol mto
the duodenum are carefully observed, particular attention being jiaid to the
prcscnco or absence of small defects in or constrictions of the common duct
The iiitrahepatic ducts are often fillerl These appear rather hke the hpiodol
filled bronchi, progressive!} diminishing m size, and terminating m fine sharp
pointed nrbonsations Dilatation of the mtrnhepatic ducts mth clubbing of
the terminal branches is an indication for prolonged drainage, and also signifies
that the biliary infection nece««)tntmg operation was present for a considerable
time
DISEASES OF THE LIVER
The visualisation of the hver and spleen b} direct radiography is \msati>.
factor} It was found that radio nctne sulisfancea., when injected into the
hlood-strcam, tend to be retained in the reticulo-endotliehal svetem — as these
substances are of high specific g^lv^ty tlic} arc radio-opaque, and one of them,
thorotrast, has Ixjen emplo}e<l for radiography of the liver and spleen The
results obtameil did not matermll} assist dmgno'is or rc^careh, and as the
half value period of thorotrast is higli and the substance is known to be
cnrcHiogcnic m aiumnls, the method is iallrngintu di*u-e
342
BILIARY TRACT
"More important, from tlie nuhologist s point of \icw, are the liver necro'-e<
In acute liver necro«i‘i, tholecjstogniphj la contraindicated There arc,
however, coses of ulnpothic jaundice associated vvitli subacute necrosis of the
tuj JIS 1 ii>i<Mlfil rl olatn.if>rair» in n <»■*!. of tililrv fotlowmB <1 -stniefion of U'l
rommoii I il* -<luri T h ^nll H i i r I a<l lin n rwn«n»<l Tlif* irr»s.uliir mn.'M of I piol jI h on
>1 skin nn I III tlx oiiiiii an I th (In >c»tnu{.iit tulip ro| row nt^ l> t UiliUtl hc|>ntio iluct
hvtr liitrc are inanv (Uj;re<s of siibuute lutrosis and the cuiiditioii does
not ai war to lx* ver^ nm* ( w/Iiw/m haviii" recent!} Iittblishcd twentj pixivcn
ea«es Tht itiohi,:v is coinpktilv iiiihnoun birternl mfictions h}J)JiiIis,
aliohuhsiii and <lni;;s having leen extludetl In wimt of Ciilhiiati'it tascs
THE PATHOLOGICAL BILIARA TRACT
343
cliolccvstograpJij was earned out and shoT^etl either a poor concentntjon or
a complete failure to concentrate This was mterpreted as being due to a
pathological gallbladder but Ciiftinan thinks it was more likely due to a
damaged power of excretion of the hver itself Tlus finding is of much interest
because (a) it shows tliat choleejstographj is not necessanij dangerous in cases
of jaundice and (b) it re\ eaK another and apparently not infrequent condition
whicl) nia^ be resixmsible for poor or absent concentration If IT hiialer a and
Frted a exjiennients on dogs arc vabd m human beings cholecystography anil
not cause distress and the dyewalllic concentrated normally when roughly half
the livens put out of action b\ necrosis Generallv speaking it is w jser m cases
of jaundice to maJ e u«e of the single dose oral method
THE GALL-BLADDER AFTER CHOLECYSTOSTOMY
Jci Iinson and Foley followed up a senes of -8 cases who had had surgical
drainage of the gall bladder They found 10 concentrated the dy e normally and
contracted normallv after a fatty meal Seven showed feeble concentration or
complete failure to concentrite and 2 showctl a normal conoentration wath
viable stones
THE EFFECT OF EXTRABILIARY DISEASE ON CHOLECYSTO
GRAPHIC FINDINGS
Moat text bool s on the radiology of the bihory tract cite numerous extrinsic
conditions as being potential causes of failure of the gall bladder to concentrate
the dve Cnllnmn has showat that the gall bladder wall to some extent con
centrate the dye in cases of advanced hver disease \eua«(m has established
that in the neurn muscular disturbances of the biliary tract there is no failure
to concentrate although such dvsl inesias are frequently associated with func
tional disturbances of other organs It has been “fated that tho gall bladder
docs not concentrate the dve in the late stages of pregnancy but this requires
verification on a large senes of ca^cs with the intravenous techmque In a
very interesting paper Good and htrlltn nnalvse tho cholecy stographic findings
m 7J3 ca«cs of x>eptic ulcer pernicious anxmia thyrotoxicosis myxeedema
diabetes obesity puhuonarv tuhcrculosis and chrome appendicitis Of the
733 ci«es ir? 1 ad abnormal cholecystogmpluc findings in the form of a jx>or
or absent shadow Of these cases 104 had the gall bladder examined either at
ojKration or autopsy and the tholecv stographic fiiulings indicating gall bladder
pathology were confirmed In onlv 2 of the cases was a nonnal gall bladder
fdun I at ojieration i e an error of 1 l> per t^nt 'Ihese findings show that
extrinsic diseases both metabolic and alxlommal have little or nothing to do
watli tl e nbilitv of tho gall bladder to concentrate and excrete the dye Tlie
majority of errors m diagnosis arc made on the interpretation of {wor shadows
surfi errors would soon be cliininatod if raihologists checkctl their jxior
shadow fitidiiigi in the operating theatre
344
BIUARY TRACT
RtFERFNCES
Amomcci. r, ” Kapil! niolccysto/npliy,* Prette J/AJ , Juni', 1932, 983
IJoTnrv, L A., “Tlie Acceworj Gal) Lladder An Emlirrolocical and Coinparafi
Study of Aberrant Vesidc*! Ofcnmog id Jfen and Domestic Animalii,’ Amer
Arutt , lft2B, 17“ , “ BebaTiour of the Human CalJ Idailder during Fasting and
KcTKinse to Food,' /’roc Ror Ffp Biol nnd Mai., 1926-27, XXIV, 167 "An
Analrsis of tbe Kcaction of the Human Gall Madder to Food." A«at Pre. 1928,
XXXIX-XL, 147-192
BPAiLsroPD. J F . ‘ Use of the Erect Posilioti in Cholecystograpliv for llie Dcmonstra
tion of Floating Gall stones, Bnt J October. 1937
Biucn^cumfig, W , ‘ Kcdnplieation of the Gall Madder,” Bontgenj>riuri», 1033. 594
Brosnee. n , Results of Inve«tig^tioti of the Gall Madder MouIiIa Lt Cljolecrsto
grapln. Forttehr a il Gfb d nonlgenifrh Jan. 1929
PutErNAV 1 R. ‘ Idiopathic Jaundue Aseociateil vith Subacute Necrosis of the Lirer,'
At Rurf* Ilo/ip I,’epl» , XXXIX, 55
Ettivoer, Alice Visualisation «I Mimjte (tall-etOHCR, ' Atner J Roentgenol , Feb 1936
Flint, E R , " Almonnahtics of the Right Hepatic, CT«tic, and GastrcMliiodeml Irtencs
and of the Bile dnets. Uni J Surg 1922 X. 609
ffOOD, C A , and Kieklin. B R . The Influence of Extralnliarr Disease on the Function
of the Gall Vdadder Amer J Roentgenol , March. 1937
GRAiiAlt, t’oLF, CoPllJP and tfooRE, Diseases of the Gall Madder and Bile ducts, ’
I^ndon 1929
Gutman, R il , See Nfmoutl* Accl-te 96
HarTUng, A , Gall bladder on the I,e(t Nidc. Uonlgrnptaxit 1032 393
HrFFORii. (. . Po«t-operatiie Vuunheation of the Biliarr Tract Apier J Uoenl
genof , Feb . 1937, 164
Jenmn<on, F U and Folli, .1 M , Cholecyeiographic Finding* following CToIecrs
teelomr, Amer J Poentgeaof Mpt . 1936
Kirjclin, B R, CholccTStograp!*'^ Unt J liadiol , 1035 VJIJ, 170
Knot R . Radiography in the Lzammation of the Gall Madder, Arr/t AVxfiol and
Flectroffcer . Julc. Aug and Sept , 1919
MAcCAETT.quotedbi Ro(XE'TONandMcSEE.Jnn , London, lOIO.C'I and 1019. 131
MEDtXMAii J I* , ChoIeciKtir-colonu Fistula /hid . July 1030
3 IOtmiia}>, Ixiru, quoted hr RoLLE.-tON and McNpe Unt J/eef J. I, 1
Neucilks Arctm The Radiologr of the Bdiair Tract.’ Pans, 1934
Xeiiman, C, Phjsiolop^ of the tisll Madder and it* Functional Abnormalities, the
GouUtonian Lectures for 1933 The l/anret 1073, April 15lh, 22nd. and 29th 785,
841. and 896
Kolleston. Sm H and McNee f DissasesoftheLuer, Gall Madder and Bile ducts,
Ixmdon, iOIO. 3rd Idn
Rowhen L., Chapter on the Gall bladder iii IHpclat « “Tlie Digestive Tract, Cam
bridge, 1933
bTAETZ. 1 S, Cholecmtir colonic Fistula. .Imcr J Roentgenol, Grtober, 1036
SrEVCAET. M , and Illick 11 Adrantage* of Intensified Oral CLMeeystngrapbv. '
4iner J Rocn'gewof , 1937 XXXIII, 024
TATEia.A. ChotecystograYilue V.xamsnatioiift. Rontgoipmri*, I03l, "31
WtsTV'.'.AU, b. . 'Javos'a brimtvaNvwv. i.vvA QAlva-cv. Twcl,
ZetUcr / Kltn Vtd . 1923 XC7 I, 22
M HirAJtEP, L, Tlie Double Oral Methml for CholeeTslograpbv, Amer J
I ornfgrnol . FetiruarT 1976 , The Meehanism of the Galt I ladder -Imef J
Vhyttol , JP’O.LXW 111.41) . rxi»erHReei««ith(holecystography including OWrra
tioiis on the Function of the Gait Idadder, J Amer Jfed ,!»»<«• , 1026, L\XX\T, 239
WiiirAKCR, U. and InrEU, B 51 . The Effect of Lirer Damage on CholecystographT m
Dogs bv the 1st ol Vidioin Telmodopbenolphtlialcin. Irch Ini Bed, 1926,
XWMI. 398
/appaLa. quoted bv ANTONLcn, C. Pretie Jfal , June. 1032, 99'
a
PART THREE
THE ABDOMEK
BY
S COCHRA^’E SHANKS. Wd.FRCP.FFR
PART THREE
THE ABDOAIEK
CHAPTER XXIA
THE LIVER, SPLEEN, P4NCRE4S AND ADRENALS
THE LIVER
General Hepalic Enlargement — Tlus tuij Ije clue to many cau^e?, such as
congestion cifTho^is tumours or hjd^ticl disease
There are certain anatomical features m the h^cr of nuhobgical import-
ance The upper surface is »> contact with the diopjiragm the left border
CNteniling on an average lialf across the left dome Its contour is there
foro cJearlv visible m a radiogram except where its shadow fuses wnth that of
the hevrt The right surface is m contact with the lateral abdominal wall,
and can usually bo made out m a film of good quabtj Frecjuently also the
anterior and right lateral margins of the liver are a isible The outline of the
anterior margin gradually disappears to the left In spite of this, accurate
estimation of slight or c\ en moderate enlargement is impos'»ible, because of the
varjang obhqmtj of the inferior surface Onlv when the enlargement is con-
siderable can it be shown radiologicallj with certaint>, and then the condition
I* evident clinicallj
The shape of the hepatic shadow varies vaith the habitus In hj^iersthemc
subjects It 18 wade and shallow, and lugb in the abdomen In hj'posthcnics
its transverse diameter is less its depth mcreoseil and the indentation of the
waistline of the patient is frequcntlv vi'-iblc on the right The hepatic flexure
and transverse colon if outlined vntb gas or hanum may delineate the lower
surface approximately but watlioiit anj precision since thev tlieni«elves are
‘50 vanablo in iwsitfoti Lojjlcrm 1914 pointcrlout tlmt if the colon ls inflated
tho transier«e portion usiiall^ bes against the lower surface of the hver, and
tliH provides a more accurate lioundarj mark but tlie method is ver} seldom
used now
Angulation of the tulie so that its ecntral rnv is m tho plane of the lower
surface of the liver ma> intcnsifv the shadow of the lower margin {Kdhhr)
Hcpato-licnography — ^For thi«. examination thonum is used as a contrast
medium This element has an atomic numlier of 116 (atomic weight 2‘}2),
and IS one of the heaviest metals known In suitable non toxic combination
it forms a den'O and verv satisfactorv medium in rcHtuclv dilute solutinns
317
348
THE ABDO'\IE^
It IS used Jii t«o forms stable and flocculent The flocculent fonn diagno
tlionno IS described m the section on the colon An example of the stable
form IS thorotrast descnbcil b\ the makers Hejdeu of Dresden os a stabi
h«ed thonum dioxjdsol containing 2o j>er cent ThO in stenle suspnsion
and supplied m ampoules containing 2«i cc It is miscible with water or
normal saline without disturbance of tlie suspension
Thorotrast is u'^cd in two diflcrcnt classes of contrast medium work—
intravascular and introlumenal In tbe former category are artenography
and Iicpato henographj in tbo latter are urograph} and demonstration of
fistuloi empyema ca\uties etc
PaorritTiES — Thorotrast is \crj opaque to \ raj's even when diluted
threefold this qualitj makes it of yalue uhen onlj a small quantity or a thm
lajor can lie introduced
Although It uas onginallj claimed to be quite non toxic in the doses recom
mended in jntra\cnous or intraarterial injection and non irritant nhen
mtroiluced into the bladder and kidnej one feature must be Iwme m mtnd'-
ita radio actu itj This is i cfj slight but since the reticulo'cndothchal sj^tem
stores thonum dioxide indehmteh when the latter is injected mtmvascularh
late degenenitiTo changes arc apt to occur in the liver and spleen m the course
of jeara Indeed imracroiw cases of such damage are now being reported in
the htcnvturc It is therefore not a medium to be hghtlj used mtrav ascularls
This fear of damage bj radiation docs not applj m the other u«e8 of thorotrast
eg pj olograph j
AnurMSTRATiox Fon Hepato UENoanAPiri — A total dose of 50-75 c c
of thorotrast is usuallj necessarj given over a penod of several dajs An
initial intravenous dose of 10-16 c c depending on the sue of the pvticnt
should lie given slowlj over three to fire minutes on the first dav As a
rule no after effects result but occasionallv sbglit licadache and rise of tempem
ture maj occur Sub«cqucnt injections should be given dailj if there are no
aftcr-eflects andeverj second dav if there are until the required dose has been
given In the absence of sjinploms it is safe to increase the dnilj do^e to
20 J'ice but if after -cfiects haveoccurred it 13 better to keep the do'^e low
Tlie radiographic examination should be made one or two davs after the last
ilose to allow concentration of the dnig to take place in the reticulo-endothehal
pvetem The radiographic technique should be directed to obtaining the
greatest possible degree of contrast aincc 11 o degree of concentration is not
great
RADiocnAniic Apii vii.vxcis — Tlicse have lieen desenbed bj LoJidar
I oltrer At a result of the fixation of the thonum salt bj the cells of Kujipfer
in the liver and spleen these oigniis cast n muili denser shadovi than normallv
ami their outlines m n radiogram bciomc clcatlv defined
The chief value of the niethoil is in the demonstration of hepatic metastases
These since ll cj do not l>ec< me iinj rcgiiate<l with thonum stand out as clear
THE LIVER SPLEEN PANCREAS AND ADRENALS 349
nreas in tlioJiepaticsIiadon Hjdatwl cjsts arc similarly dehneatcd I ohcef
states tint in ndNanced cirrlioSB of the liver the concentration of thorium is
jKXir and that the physiological rhythmic contractions of the spleen can he
obser\ed fluoroscopically The method is said b\ VoUcer to be contra
iiKlicatctl in diseases of the reticulo-endothehal sy stem
Thorotrast hepatography and pneumoperitoneum may both gi\e accurate
information regarding the liver but the now well known damage w Inch thorium
inav do to the roticulo'endothehilsystem precludes its use m the vast majonty
of cases and the information obtained b\ the latter method is usualh not
worth the incom emenco of the examination
Abscess of the Li\er — Tlic small multiple metastatic abscesses follow mg on
p\lephlebitib or ulcerati\e cndocanlitis giNC no radiological signs The larger
nmccbic abscesses may cause enlargement of the liver and elevation and
fixation of the right dome The nearer the abscess is to the upper surface of
thehver the more definite arc the«e signs The dome is not u«ua!!v deformed
ev en w ith a subdiaphragmatie liver abscess but m tins type the cliffercntial
diagno'^is from pubphremc abscess may he impossible
Carcinomatous metastases of the Uver are very common Apart from the
ad\ance<! cases m which a mass can bo seen projecting from the lower margin
of the liver and the extremely rare calcifying metastases radiologv is of little
help Anv general enlargement shown in a mdiogram is also evident chmcally
rhorium hepdtogmphv is now regarded vntli disfavour even m this condition
It show 8 intraheiHitic metastases clearly and may b\ doing so spare the patient
an uniiceessarv laparotomv In such a case thonum damage is of no con«o
ciuencc but if no metasta'cs are present and the primarv lesion in the ah
inentarv canal is remov able the damage caused by thorotrast is of importance
and the method should therefore be avoided
Calcification in the Liver -^The liver is the common site of hydatid evsts
They mav be multiple and reach a large size If near the upper surface a
evst mav cau e a localised roimdevl elevation of the diaphragmatic contour
and if near the anterior margin a roundeil downward projection of that edge
{Hurnfon) More commonly however tlicy are not radiographicallv recognised
untiHhev Iiecome calcified as often hapjien'j As the wall calcifies an irregular
trebeculatcd ring shaJow of the wall appears the arrangement depending
on the distnbution of calcification and the arrangement of the evsts
timard reports a case of tuberculous abscess of the liver which had under
gone calcareo sclerosis and cast an irregular sliadow simulating gall stones
/’rcfsp reports two ca^es (1) Opacities the ''i/e of clierry stones scattered
throughout the liver and thought to be due to calcified tuberoulous foci
(2) \ large irregular calcified inn«s capping tlie upper surface of the liver from
a talcified subphromc abscess
Other conditions m the liver which mav rarelv become calcified are
liaimangioma and Ivmpimngioma abscess gumma and metastatic carcinoma
TUB ABDOMFN
THE SPLEEN
Anatomy — The bpieon hes postenorJy in tho left hjpochondnum Iwtween
the gastric fundus and the diaphragm It is an oblong flattened bod) about
■> inches long 3 inches broad and I 5 inches tiiick It is held in position hi
the heno renil ligament and the gostro splenic omentum The outer comex
surface is m contact uith the iliaplimgm ulucli separates it from the ninth
tenth and eleventh left nhs lU inner surface is divided bv a ndgo into an
anterior or gastric surface ami a posterior or renal Tvxo other relationships
maj Iks noted that of the lower pole of the spleen to the splenic flexure of the
colon and tliat to the tail of the pinercas Tlie long axis of tlie spleen runs
from above downwarfls outwards and forwards
Radiological Appearances — The nonnal spleen js visible onl) if contrasted
niodiall) against gas or other medium in the stomach and/or colon Usinllr
Its upiier pole is to same extent visible against the gastric gas bubble and if
the splemo flcMiro is distcmled w ith gas its w hole inner contour may be seen
but percussion and palpitation give aucJi accurate information regarding its
|>osition and size that radiograpliic examination is seldom if ever necessarv
If it 18 ncecssarv to demonstrate the spleen mibologicall) the patient should
bo screened to determine which view (pobtero anterior oblupie or latcnl)
phoHb It Itcst and whether it is necessarv to inflate tho Btomaeh and colon
Its normal outline is tisuallv semilunar but mar varj according to the angle
at which It is projected
Ptosis oi the sii i ts is not an infrequeiit occurrence and is demonstrated
onlv m the erect posture Enlargement of the spleen is cosilj detected
climcnll) and its radiological signs in addition to the increase m its
shadow arc those of disphocment of the stomach to tlie right and of the
left colon downwards
t ALoncvTKJx IN THE SrLtEN ma) result from vanous lesions including
the following tuberculosis infarct ii)dntid disease phlebolith
C ALcmm fv HI Rcv un r«)n appear as multiple rovmdctl irrcgul \r
shadows usual!) siiinll in wre scattered in the splenic shadow In the case
reported bv ^pilz thi opacities were small and sliarpl) defined and the
calcification well ad\ancetl In ono of Sfiaidt three cases the opacities
were larger and soujcwbaf due to active casealjon m addition to the
calcification
‘'ll tsir Imawc-t pre'*ents n Ijpital iiuhological appearance when calcified
AUIiougli iiifarcth are not uncommon calcification in them is and so is rare!)
seen in an \ ra\ department Kadrnkn and liabiaMz descrdie the following
features in three caspa seen b> them The ealiified le«ion is of constdecahlo
sire locatisl in the spleen of tnangular or ovol form and ma) be single or
double The texture of the calcified shadow is not homogenoous but rather
porous If triangular m sbajK* the baso is to the outer convex surface and
THE LIVER, SPLEEN. PANCREA«?, AND ADRENALS 351
jts ape\ towards the hdum The contours of the tnangle are sharply defined,
TTitb minor irregulanties onU
The shape of the infarct as seen in a radiogram — o\al or tnangular —
depends on the angle at which the p>Taniidal lesiorr is projected on the
film
Hydatid Cysts cau«e enlargement of the splemc shadow if not calcified,
and, m addition, the t^Tiical trabeculated nng shadow if the^ are
PiiLEBOLTTHS are said
to result from Yenous
thrombi Tliej apjiear as
small rounded shadow s
varjTng in size from 1 nini
to 1 cm and ina\ he
multiple, as in the case
reported by Koppenfletn, or
single as in one cnee noted
bj the wTiter
Rare causes of calcifica
tion winch hiYO been dc
senhed are atheroma of tiic
splenic artery and
perisplenitis
THE PANCREAS
Anatomy. The pan
crcasIiestransYersclyontlic
posterior abdominal wall in
the epigastric and left hypochomlnac regions at about the le\cl of the first
lumbar vertebra Its downward tumeil head, the largest part of the gland,
IS closely encircled by the duodenal concaritj for about two thirds of a circle
Radiologicallj , the most important anterior relationship of the pancreas is the
sfonmeh, which hes in front of most of it, separated from it by the lesser sac
Ihi duct ofWirsung opens into the second part of the duodenum, 3-4 inches
from the pjlonis, cither directly or into the ampulla of Tater The common
bile duct, as it approaches the ampulla, is also closch related to the pancreatic
head
Technique of Examination — ^Tbe pancreas is a difficult organ tocxnimne
rndiologically, and a variety of measures may be necessary, depending on the
lesion in question They are
(1} T/ie Platn PiMtero^ntenor Film — ^Tlua may show gross cnlargcmci^
or calcub, ami in acute pancreatitis may gi\c confirmator\ signs
(2) The Jiarium Heal may show a gastric or duodenal presaure
Ttcuung's method is of particular calue Iierc In this method tb»
Fir — rhrw> l'plenI^ ntonp^
352
THE ABDOMEN
Tiell filled vith banuzn emulsion is
radiographed in the lateral (dettru
sinistra!) sic\i, with the patient Ijing
supine, and the ra^'s honzontall\
disposed A Schonander grid is U'cd
Tutntnij points out that m manj
ptotic women a normal incisura is
present on tJie jxistcrior wall of the
stomach at the level of the pancreas
(the * posterior pancreatic mcisura )
This shows itself in the postero antenor
supine Mcw as an indentation of the
greater cuiae sometimes extending
right across the stomach but more
frequently fading n\va\ towards the
Ic^'cr cun 0 (Fig ’-15) In tlic lateral
ofTwjiun)? I *«iew anwnor tupifK* MW supine xaew tliis incisunv IS seen to be
an infolding of the gastnc wall at the
pancreas surmounting a triangular filling defect due to the pancreas itself
(Fig 240)
Tlie recognition that there is normally a triangular defect present in addition
to the incisura pro\>er is <«f importance in asse'vsmg the presence or absence
of one duo to a tumour of the pzincrcas or stomach bod
(3) FluoTo-icoptj of the Diaphragm and Lung Dn$en should !ie earned out if
an acute jiancreatitis is examined radiologicahx
(4) The Unnum bnnna mn\ giro c\idcnee of slcatorrhaja m chrome
pinrrcatitis
(>) Lnferid lindiogrnphy uifh
tiriii/atioM of Ihf Slonujfh —
The teehniquo for this last
aritirdinp to hntjfl and Lyiholm
H important ns follows
Hie colon should Iw well
eSenred out and t!ie storoarb
iruytx The Htoinnch is inflated
Ma an hmhoni tulic (which
max first }»o iistd to emplx
It) and the patient told not
to lieleh If the patient objecta
to llie iMiKsnge of the tulic an
effcrxcscing powder max be u«ed i
but tins neccs.sitates swallowing p,„ _tj,p i«-terH r (r«niT.-«i.c) mrw.m ot
some xxater wbiib is a disad laitml Kopinf mw
THE LWER, SPLEEN, PANCREAS, AND ADRENALS 353
^ antage hicliever method js u<%d, the Jateral radiogram must be taken
unmediatehj after the inflation, before any appreciable qnantitj of gas
has escaped into the small intestine In that site the gas may cast confusing
shadoA\‘S
The patient should he prone \ntb the cliest and pel\ is supported by fiat
pdlou'^ or pads to preaent undue pressure on the air filled stomach Alter
nativclj he maj be supine, but this position gives a less prominent shaJow
of a tumour
llie tube Ls centred honzontalK on the nglit loin, and the film placed on the
left A Sclionander grid niav be used with advantage Immediately follow
mg this, the essential view of the technique, a prone postero anterior view with
grid niaj be taken to determine anj lateral displacement of the air filled
stomach or tumour shadow m air rehef
Engel and Lysholm in a senca of investigations of the normal, using 100 cm
tube film distance found that the average “ pancreatic space ’ between the
spinal and gastric shadows approximalcly equalled the wadth of the adjacent
vertebral bodj In enlargements of the pancreas this is widened, and the
contours of the enlargement «een against the air filled stomach
Of the two methods Ttnnxngt would appear to be the better, smee it
av Olds the use of the Einliom tube and since banum is a better contrast medium
than air In large tumours the Scandinavian technique might bo used wath
barium as the medium instead of air
Acute Hsmorchagic Panaeatitis — ^This is an abdominal catastropbo vsath
a high mortalitv, and is rarelj examined radiologically It mo^t commonly
rcsulfs from retrograde infection along the duct of Tlirsung from hiliarv
disease The most sev ere typos mnj die from collapse m twent j four hours
If tliev survive the initial shock, aWeess formation hjeraorrhage into the
pancreas, and fat nccrosi& are typical features
Haring states that an antero posterior film maj show blumng of the outer
margin of the left p^oas muscle m its upper part, from the enlarged gland, and
nl^o that the left dome of the diapliragin is immobile or nearly so According
to Udvardy, bilateral basal pleuntis and pneumonitis maj occur from acute
pancreatitis vnth ab'sccss formation similar to that seen on the right side in
subphrcnic abscess If a pancreatic abscess contains gas, it might lie visible in
a lateral supine view , w Inch vaew niav alM) show an enlarged pancreatic space,
if the stomach contains air
Chronic pancreatitis gives no localised radiological signs since it rarely,
if ever, causes pancreatic enlargement Steatoirlicea is sometimes a feature
of this Condition and mav pre<s?nt a honev comb or polv'poid appearance in the
colon after a barium enema {SUnilrom) Careful lavage before the examma
tion wall diflercntiatc this appearance due to retained fat, from true jxilvposis
of the colon
\ u 11—23
354
TIIE ABDO'MEIC
Pancreatic C>sU — ^The«e arc rare Orey Turner cla'isifics them as
follows
Tucf C\sts
ylriiioMs — (1) Retention (2) C>stadenonn (3) Congenital cystic
(iHCOse
Inferacinous — (1) Lymphatic (2) Parasitic
PALSF CiSTS
Intrapentoncal — Inflammntoiy effusions into the lesser sac from
injurj or pancreatitis
lletropmionea} the result of breaking down of new growth or
hsniorrJiagc or abscess of the pancreas
iRth C\STb — The retention tjjio is the commonest and usualU results
from obstruction from clironic pancreatitis The«e ejsts are commonb as
large as an omnge and maj lie enomioiis H\datids are rare in the pancreas
hut also ma\ lie of considerable sue
Feust C\STS — Tlierc are two tjpes both of which maj be large
(1) Loculatcd inilammatorj effusions in the lesser sac in front of
the pancreas
(2) Localised rctropontoncal effusion following the breaking up of the
pincrcAs from old pancreatitis
IlAoroLocrcALl F-iTcnto — A cast if of some size nia^ be aisible in a plain
[Hiitero anterior film In n Uteri! view with stomach filled with air it produces
a rounded forward bulge into the gastric lumen
Tins prcRsure effect is aKo aisiblc in a I arnnn meal A aarying filling
defect IS produced in the stomach the size of the defect depending on the wze
of the cast and the degree of ftUnig of the stonmeh Small cysts maj produce
no gap in tlic gastnc shadow unless onlv a small amount of barium is present
TIu defect la tiien seen m the pars media ccntrolh or towards and invclamg
the Ics'cr or greater curve dejiending on the exact site of the forwartl prutnul
ing mass The dofc ct fades awaj toaraitls its margins and at the margins (ho
mucosal folds are seen to be normal holler points out that the stomach if
filled sufiicicntlj to blot out the defect show*, an apinrent mere ised flexil ihty
to the palliating hand during fluoroscop) ^ era slight pressure is ncccssarj to
cause a gap m the barium shadow since onia a thin laj er separates the gastnc
w alls ot the site of the ca st In a case seen bj the wnter the same effect was
noted wath the patient prone ashen tic defect maisible with the patient
standing np;>cnrcd
Ijirge easts ma\ jiroduco an extrBj.ahtnc defect aihich is not obliterated
La complete binum fllimp. or maj cause a marginal defect watb literal
displacement of the stomach A aera large c>flt maj produce a gap extending
right across the Rtoniach Oerth reconis aiich a cost in which tlie cast was
also visible ns a faint rounde*! opaiita m a I lam filni
THE LIVER, SPLEEN, PANCREAS, AND ADRENALS 355
A cjst near the head of the ^pancreas may cause a filling defect at tlio inci-
8ura angulans One m the pancreatic head provides a doformitj similar to
that caused by carcinoma m that site
J/o»a«ru has reported a case which showed first as a closed cjst, deforming
the stomach Later, after the c\st had ruptured into the stomach, a banum
meal showed the cjst outlined with bannm, and presenting three lajers, of
gas, pus, and banum
Carcinoma of the Pancreas. — ^Thc
common site for this is in the head of
the pancreas, where it produces tjpical
clinical and radiological features The
clinical picture is governed bj the ob
stniction of the common bile duct with
graduallj increasing jaundice, dis-
tension of the gall bladder, and
steatorrheoa
Uadiolooicalli , the duodenum
shows widening of its circle, narrow
ing of Us lumen, and distortion of its
plica? When the pancreatic enlarge
incnt IS gross, the pvloric antrum roaj
bo raised and the duodeno jejunal
flcMiro depressed (Fig 247) Gastric
stasis IS a common result
Pancreatic Calculi. — These are rare
According to KdhUr, thej are found
in the ratio of 1 in 2,000 autopsies
They have to he difTerentintcd fiom
the upper abdominal calcifications,
renal and biharj calculi and from calcifiwl gland-j They are commoner in
males, and usually develop aftei the ago of 30
RAWoixioicAn rEATTREs — Paiicrcntic calculi contain calcium, and are
therefore visible in a radiogram Tlicj are ncarl^v alwavs multiple, and are
haarCAnani' jTTc^nn'tnlj icibng' tAu Awnf ami' of gArmf rberr siVapu
imj l>e flcck-hke, pointed, faceted, iniillierrj, or (rarelj) round. Haring
records an annul ir form
In a radiogram the shadows of pancreatic calculi are usually disposed
transversely or obliqucR across the middle abilomen at about the level of the
secoml lumbar vertebra
Graham Hoil'json roeonls a case of sobtnrj calculus in the duct of Wirsung,
diagnosed mdiologicall} h^ combined cholccjstographic and banum meal
evnmmations The former excluded gallstones, and the latter showed
the opacitj within the duodenal circle, close to the ampulla of Vater
Fig 247 — Cart-monift of the heod of tlio
pancrca/) proiluciriR elevation of thepjlorio
Qiitruni and widening of the duodennl Circle
35G
THE ABDO'MEN
Coh records a cise of calcification in a carcinoma of the head of the
pancreas S i\ Senndt records a case in which the cilcuh were large— up
to 1 cm in diameter — irregular m contour and scattered throughout
t)ic length of the pancreas Tltcir distribution made the (Uagnn«i3 fairl>
definite
THE SUPRARENAL GLANDS
Anatomy — The supnrcnal glands are two small llittencd bodies capping
the iipiicr jKiles of the kulncis The right is more or less triangular in shape
the left lunate They are about li-2
inches m length rather less in width
and 1 2 mm thick The ^lostenor
surfaces of both are in appo ition to
the diaphingm abo\e and to the upper
poles of the kidneys near the lower
margins TJie anterior surface of the
right IS related to the liver and inferior
vena cava and that of the left to the
stomach and pancreas
The normal suprarenal glands are
invisible in a plain radiogram but can
be shown by the perirenal mtiation
metluxl of Cnrelh (Fig 24S) or b\
pneumoperitoneum '\\ hen demon
strated by either of tlicso methods
tliev each present a chamctert'»tic
outline
The tv\D conditions in aihich the
or ^ r I I Ti 0 HI I ra i«-i art- normal radiologist 8 help may !« sought are in
n n innal pnlarppmpni to fcM.lrmi liimours of tlio gland niul in Addison 8
ihscasc
Adrenal Tumours — These are rare and are iwunliy diagnosed chnicallj
or radiologicallv onlv when they hare reached Bonic size ns m by pcmcphituna
and nruroblastoiua Thp\ tisualH occur m children Isolated cases of ghc ma
neuroma ghofibninia angioma lipoma and cysts have been descnlicd
The adrenal hv jwmephromas may bo benign or malignant and arc mikI
to arise in tlic adrenal iortc\ {Thomsott 11 alLer)
l^argc adrenal tumours innv give ev idence of their presence in a plain fd'u
(1) by their own shadow (2) b% downward displacement of the renal Hhad >«
I’\(!ogrnpli\ mav siiow certain fiafurcs According to Ca/iill hiir-rok
Slofil ami Smtlli when tlie kidnev is displacetl downwards the upj)cr jx k h
bomctinieH rotatcil inwanls with the hilnm facing downwards In ncplm
ptosi- and ectopia this rotation does not tvpicallv* take pi ice If invasion i f
358
THE ABD03rE\
tht upper pole of tlie k«lnc> occurs distortion or obliteration of the upper
caJ\ces results m ulnch wise the difTerentmtion from rensl neoplA-®ni mav be
(liflicult or inipobSible
ritrco other methods of demonstration of adrenal tumours ln\e been used
with success IVnrcnal inflation outluies the suprarernl capsule but is rirelv
used because of the tethnical (hfncuttics The technique is de'>onbed in the
section on the uniiari tract Langtron in 192'J demonstrated an adrenal
tumour bv pneumo|>eritoncum Ihe radiogram must be taken \nth the patient
prone Itoux Berger XanUeau and Condtades (1932) injected m one case
40 c c of thorotnst into the aorta and bj thus outbning the arterial supply of
the kidnc\ tumour and spleen were able to demonstrate tlio presence of a
cortical adrenal tumour It is a moot point w hetlier exploratory laparotomy is
not a more satisfactory procedure than this last
AdrenO'gemtal Syndrome — According to BroUer this syndrome that of
Mnlisni 13 caused In cither ht'perplasia of the adrenal cortex or a cortical
tumour both charactcn''ed b\ fuihsinopliil cells The symlrome ma^ appear
when the tumour i« quite small and m these cases plain radiogmphv is of
no help Perirenal inflation is then tlic only practicable method of \ ray
demonstration
Addison $ Disease — \\ hen the tuberculous process m the adrenal gland has
progressed to caseation and or calcification the latter cm be shonn radio
^.raphicaih Dal! Oreene Camp and Rountree out of twenty three con
scculise cases huccc^sfully diaguo«<Kl si\ radiographically using a right oblique
MOM for tlie left suprarenal ami vice \ersa the tube being tentred over tie
tip of the xiphistcrmim fins tcclimquc avoids the supenm|>ositicn of tie
sliadnw-H of calcified costal cartilages
brom a cauubmcil study of films taken iii vno and of isolated jwst mortem
t«|)ocimens tliese autliors clis ify the tapes of adrenal calcareous phadows a-s
f UoMs (I) gross calcification of the entire gland (2) discrete areas of calci
tication scattered throughout the gland (Fi^ 240) (i) homogeneous increase
in the opKita from the gland The last is probabli due to caseation To
tlie e three groups ma\ Iw added that shown m lig 250 m which the calci
fication outlines the gland like an incomplete tralieciilated shell
1 F Pagne ilenionstrated caseation and cnlcificntion m three eases of
wie M wspocnAiaA tiitVi gtt/s* Va’oftrcv.Vtv.'.s eoseo
calcifiration of the right kidnev
TEFI RENCI S
XiMiri J J Iniot lUrlrol 1031 WII 41
IlsiL H !• I PiFM t II (in 1 t s)ir I D Iwer J I oentgeMl 1034 \\-\I 03
Hro-Tni 1 R /x rt 1031 I fi3 >
1 AiiiLL. C F at 1 OtiiUts Sury Olufel 1030 I \II SS"
l inFLti If H an 1 Viitr rLLi 4 I rr 1*« Mel Irjrnl lO’l \\\iy 4*’!
Luix. I (, Mtl \/r» lOOo I\\V\I 441
THE Ln^R, SPLEEN, PANCREAS, AND ADRENALS 359
Evcei , A , and IiT«iiOLM, E , Ada Jiadtot , 1034. XV, 635
FaEi.«E, K , liontgenprariii, 1933. VII, 368
GriTll, F, lortscfir Qel> Pont, 1633, LI. 8
IlARrso, Sv , L'rg'ef'H med A/ra^fcn/orfwAr, 1933, 407
IlARRr'Ov, li J, “TertJrook of Rof ulgenoloja ,* Biltimore, J93C
^0I)G'lo^, H K Graiiaji, Bnf J iladtof , 1933 V, 783
Kadunka, S, anil IUBrv>T 2 , L. J Itndiol FIfftrol, 1934, XVIII, 161
KoHLtR, A , “ RfmtRenolojn lyonilon. 1933
Korppv'iTi.rv, E , lorUchr gth Pont , 1927, XWVI, 139
LAJ.r.EPOV, L , and Dwfes. A , Pan* Vtd , 1920, II, 145
LoFtLFP, IV , JfifnfA 3/«? TTrfcnsffcr , 1014, LXI, 763
Monactm, j , liontgenprari^, 1035, VII. 31
Pay\>. \ T,nril J PfldioI,1933 VI. 747
Rotnc EFRGff , J L , A’ADLtEAU, J . and CoNDrtDF-*, X J , 2?td/ Soc Ac/ Ch(r,1934,
LX. 701
SF>SPrT, $ K . SnI Med J , 1920, II. JC54
SiiAND«, II R , Amer J Surg , 1933 X\, 707
Spitz L, Pontgenpraxie, 1032 IV, 903
‘^Trv'iTi OM, R , Arfc Pcdiol , 193 >, XVI, 589
TfJOM«oN VALKrr, J \\ . Cbojpos '* Syalrm of SuTCery,” London, 1932, 31
Tci SET, G Gpft, ChoTcea ‘ S>fitem of Ourstry,” London, 1932, II
UoVAPDr, L , lio>dg<nprax\», 1034, \ I, 785
lowClB, L , iorfifAr geh Pont, 1031, XLI\ , 452
PART FOUR
FEMALE GENITAL TR\CT
R E ROBERTS, ’MD.BSc.DPH.FFR.E'MRE,
AXD
J ST GEORGE MTLSON, MC, MCh, FRCS
PART FOUR
FEMALE GENITAL TRACT
CHATTER XXX
XRAYS IN GYNECOLOGY
RADiooiuru\ OP the female peine organs is employed as foIlo^vs
(1) Simple or “direct “
(2) Corubmed inth injection of some contrasting medium such as (i) Gas
(u) Opaque fluid (ill) Combination of (i) and (ii)
(1) DIRECT RADIOGRAPHY
The normal pehic organs arc not visible in ordmarj direct radiognims
Under certain conditions, iicopIa«m8 of the uterus and ovaries cause shadows
in X rii> examination of the pelvis Tlie comnlone^t neoplasm of the uterus
IS tho^6ro?nyoMia which under ordinary conditions is of the ■^mc densitj as the
surrounding tL-»»uca Calciflcation of the fibroid, uhen it occurs, unll render it
opaque to X njs and ma\ be found m one or two \ arielies— (a) homogeneously
throughout the tumour , or (6) more commonly m patches throughout the
tumour or on the surface The opacitv, of course, depends on the amount and
the extent of calcification Calafication of fibroids tends to occur as a nile,
after the mcnoiiause, and does not usually of itself give nse to symptoms
Cnlcijietl fibroids (Fig 2oI) are therefore usually diagnosed more or less acci
dentally by X ray’s in c ises whicli are l»euig examined cither ns a routine or on
account of oliscure svmptoms Calcification of fibroids ls said to be a contra
indication to X ras treatment, but from the foregoing it will be «eeu that, as
thcMi tumours do not give n«e to the onlmnry symptoms, their treatment by
X rax therajiy is not noriuallx called for Calcified fibroids are frequently
found to be subverous and iiedunciilated m uhich case surgical treatment may
lie iiulioatcil as a result of torsion, intestinal adhesions, or obstruction
One type of ovarian neoplasm the oixir«i» dermoid, is noteworthy in that
It contains calcareous and ovsifio<l tissue m varying amount!*, which may in
faxourable ca«es gv\e rn-e to shadows Teeth are ponietitnes present, which
max produce their characteristic X ray appearance*,
Calcified plaques may al«o occur in walls of simple otrirtan ci/sls , these are
unlikely to 1x5 disclo'Otl by X ravs, owing to their small **120 and the thmne*>!3
of the calcified tissue
The rtlation of any donbtful opaque area in the pelns to '* * ’ ’ ♦
304
FEAULE GE^^TAL TR4CT
ureters maj be investigated bj cjstographj or ureterographj (intravenous
or retrograde)
W hether the tumour c<irttams opaque material or not, its relation to the
uterus can be demonstrated bj means of utero salpingography supplemented
where necessary liy pneumoperitoneum A Iielpful procedure is that suggested
b\ Berlere nameli the jirelnimmry demarcation of tlie limits of tlit palpable
tumour b\ lutans of lead w ire hxeil to the skin so as to surround the tumour
1NJECT10> OF CONTRAST MEDIA
It wasdiscoiored that the injection of n ^as into the i>entoncnI caiiti made
it possible to outline thwe organs which abut on that eaiity and any iieoplasuis
msidt In the contrast of dcnsit\ lietwccn the tissues of the organ or ncopJ'^*^'
and tlie fiurroiiiuling pas
In women pas ma\ lie introduced into the peritoneal caMtv mi the uterus
and huUapmn tulas or vm the abdominal wall Jhe fornier method is
inonlj employ c<l in tiic diagnosis of the patency of the tubes m the iniestign
tioii and tnatnient of sterility hut is contmmltcated m nsis of prignancj and
X EAYS IX GYNAECOLOGY
3C5
m infections of the uterus and tubes, uhen the latter route may be used
.\jr%%-as the first gas to be used, but inasmuch as ^sin thepentoneal cavity
m nnj appreciable quantitj gi\es nse to pain, and air is comparatively slowly
absorbed (two to tliree days) it has been found that carbon tliovide gas is
more satisfactorv, being absorbed much more quickly (in a feu hours)
tia 2 2 — Pfwis npparatas A Sparklet B BotU<* fontamjnt. strnle wann water
C Mnnorortw 1) llubuis ronniiln or bollon needle L Control wlieel
Since J?h6ih firet described the technique of transutenne inflation of the
pentoueal cai it\ , number^ of diiTercnt forms of apparatus ba\ e been dc^enbed
by i anous authors, tiding either air or carbon dioxide Alyjst authonties imist
on incaburing the pressure at ubich gas is passed through — the importance of
uhich luH be seen lattr — and otheiu al«o introduce a /lo» meter m order to
a^'Ccrtaui the qunntit\ of gas introduced
Ihc apparatus dcscnbecl by Proiis (Fig 252) has Ijeen used both for
3CG FI:^LVLE GENITAL IRACT
transHtcnne mfiation bj means of tlie utenne cannula, and for mflitiou
thro^iglx the abdominal wall by nieana of a holloir needle
TRANSUTERINE INFLATION
Tins nietbod is astd almost entirely as a test of the patency of the Fallopian
tiibe», rather than as a nicaas of inflating the peritoneal ca\ntj
Contraindications
(1) The presence of an intrauterine pregnancy
(2) Menstruation
(3) Actue infection of cervi\ or tul»cs
(4) Ectopic gestation hydrosalpinx orpjosalpuix
Careful bimanual examination ahould lie made as a prebminary, preferabK
under an'csthesia Tins examination is usualK made before inflation, os a
preliinmarj to dilatation of the cervix, tibioli is tiie routine treatment of
Htenlity Mhth ordinary antiseptic and aseptic precautions the procedure »
practically harmless In n certain small percentage it is followed by endence
of i«hic i>cntonitis and ceKiilitis, which is to bo ascribed rather to the
unrecognised jiresence of infection than to the recent introduction of sepsis
M oiieratno procedure
The Technique — Iho wnlors use the oppiratim designed by Froii-s
This (Fig 252) IS prepared by placing a Sparklet tube of COj in the appro*
pruitc holder, by filling the bottle up to two thirds with warm sterile water,
and bt attaching the maiiomctcraiKl the innmila to the tulies leading from the
T piece passing through the stopper of the bottle The cannula is previoiisly
^tcnlised by boiling
Tlic sulvn \agino and cerxix Iming been cleaned and painted with an
antiseptic the cenix is bcized with \olscIlum forceps and drawn down to the
mtroitus for inspection A utcniw sound is then passed to note the direction
and length of the caMty of the uterus The ciinniila is then pissed till the
oin e js firinlt pressed into the external os , m practice this is found to give a
gas tight joint
The s(op-cock IS then lery carefiiiU turned until it is seen that the gas is
slowh passed through the ixittlc and into the cannula Tins passage and its
rate lan be jwlgetl bv watching the icxcl of the gas biibVilo m the inner tube
and the manometer
It Lt iiniicmtnc that the first passage of gaa should be lerj slow, as tlie
sudden raising of pressure in the uterus is sanl to give nse to spasms around the
uttnne iiids of the Fnlloptnii tiilics (A’cimcrfy), and inav give a negatnc result
to tbc ff«t
*1110 reading of tbc gw pressure w xvateheil on the manometer, and if the
e of the gas is suffinenth slow, it will lie seen ton'-e scry gradually until
XRWS IX GYNECOLOGY
307
it cxjmes to a point nhen it ceases to nse, and remains stationarj or even falls
a fen millimetres Tins is taken as an indication of the passage of gas through
the tubes The ntc of the pas!«age of the gas through the apparatus is then
slowlj accelerated, niamtcnancc of a stetdj pressure as recorded by the
manometer at the previous or e\cn a slightlj higher level is regarded as
confirmation of the passage of gas through the tubes
If on the other hand the pressure shoim on the manometer steadily nscs
up to 200 mm of mercun the passage of gas is stopped at that level the
pressure is allowed to fall again to zero and the procedure is repeated
Ihe raising of the intrauterine pressure to 200 mm of mercury on tivo
successuo occasions uithout the escape of gas is taken to indicate that the
Fallopian tubes are not jiermeable
In those cases in which the raanometne readings indicate the passage of gas,
the latter is allowed to run through for a minute or two m order to collect
sufficiently in the peritoneal casjty to gi\e clinical and fluoroscopic X ray
signs The same day (or the nevt day if the procedure has been earned out
under general aniestheaia) an \ ray film of the diaphragmatic area js taken
with the patient in an upright posture when the exhibition of gas ns a trans
lucent area under the diapliragm (i e between the diaphragm and the liver)
establishes the diagnosis of patency of one or both Fallopian tubes ^\he^e
only a small amount of gas lias entered the pentoneal cavity the translucent
area may onlv appear as o thin tnangle oboa e the middle of tho liver here a
large amount has entere<l the <liaphragm an<l liver may be seen separated by a
wide translucent area extending transsersely across tho whole width of the
abdomen {Fig 2 j 3) Tlie presence of even the smallest amount of free gas in
the pentoneal caMts as scon between the diaphragm and hver is conclusive
evidence of patency of one or both Fallopian tubes
The absence of gas m this area is strong presumptive evidence of occlusion
of both tubes In such a case confirmation should be sought bv injection of
iodised oil into the uterine caMtN (see utero'^alpingography ) as occasionalK
patenc\ ofone or both tubes max be demonstrated by utcrosalpmgograplu in a
case where the findings by transiitennc inflation were negative
PERITONEAL CAS INFLATION THROUGH THE ABDOMINAL WALL
In gy na?cological conditions this method nia\ be employed in cases where
it IS inadMsable to inflate per vierum particularly in pregnancy and in
inflammatory conditions of the Fallopian tubes It is of xalue sometimes in
tho«e ca'^cs where it is difliciilt to diflerentiate snelhngs of the tubes or ovanes
from the uterus
0 echni/pie — ^There are certain technical dilBculties to be overcome which
are not present with the other method Tlio patient must be X raxed m the
Trendelenburg jwsition m order to ensure that the gas m the pentoneal caxity
flows into the peine ca% ity around the pelvac organs and tint the intestmcs as
3C8 FEM\LL GEMTAL TRACT
far as po'^ible slide into tlie upjier alidoraen Tins entails incorporating a
Potter Biickv diaphragm with a table capable of giving a good Trendelenburg
position
Tlie patient requires careful preparation ^^th regard to einptjing the bowel
and bhdder tiic latter being attended to just l«forc the procedure
To inject the gas into the pcntoncnl ca\it> the ProMS instrument la u«cd
ii -53 Irco It ( ntonriil IWnccn d nphrapm nnil
supplied witli a sharji hollow needle nt least 3 inches in length insteatl of the
utenne ranmila ««e<l m the traii-sutennc inflation
tor the sake of cnmpirison a film is taken of the patient m the Trcndclen
burg position Ijcforc iiijcetion of pas
Tlic needle is inserted with antiseptic and aseptic precautions tliroiij.b tb^
abdominal wall 1 inch below and I incli to the left of the umbilicus I/)tsl
BH'estliesift to the skin is «niiere-»!«ir> The roost painful point is the jia»«aj;e of
tlic nmilc through the pentoneum
Rofore m*>erting the needle the gas is scrj filowlj turned on to show - 3.
min of niercun pressure As the needle is pushed hteaddi through tie
nlHlominal wall the pressure is ecen to n'»cn few millimetres and to fall raj idb
again when the needle l*inctratcai the jicritoncum Tins is not onl\ a
relnl le mdic itioii of tlie entranct- of the needle into the perifonetl nvit\ but
ull tend to pretent jierfi ration of tlie intestines Passing
\ UWS GYA^COLOO.\ 3G9
the needle through the abdominal \\all is safe and easj honcier mthoiit
this mano3in re
After the mitnl perforation of the fcl in the needle is stea hij pushed
direotlj in and the oaercommg of two sbglit rc<?istances can be felt tlio first
resistance being due to the anterior fasaal si eith of the lectus mu-icle and the
second to the posterior lajer mth arhicli is incorporated (except m the aen
liQ “A - — ShnJo of KuiTO n l«l l> Iran, fu erjt frw pas n f e«fonCdl cai Cy
(Trw> Icle tn rp po>- 1 on)
obese) the pentoneuni When the point of the needle is in the iientoneal
cavitj the flow of gas is increased through it with due regard to the pressure
recorded bj the manometer w inch should not read more than oO mm pressure
Tlie wTiters hare not used a flow meter Iieing guided bv the visible
distcnsK n of the abdomen and bj tl o sensations of tl e patient
hilms are then taken wath the patient m the Trendelenburg position both
prone and supine (1 ig 2 j4)
Diagnostic Applications — In the diagnosis of xwlvic conditions Jardo
states tint the field for pneuniopentoneum is somewhat limited as it is
gcnoralK roscr%ed for cases m which pelvic infection exi-sts or in which the
1 allopian tubc-> are orcluded making the production of pneumojicntoneum b\
the i>enitenne route unsafe or imposaible Under these conditions in obscure
\ J u— 24
370 FEAL\LE OENITAL TRACT
cases, tlio injection of gas puncture of the abdominal u all may pro\e of
assistance in the diagnosis of myomata Jibrotds, ealpnigilis, cystic and omnan
tumours and in the loeation of adhesions involving the pelvic structures It
maj tlnisclariR the situation l«fore operation is undertaken and bj aecurateljr
locating the lesion ma\ limit and simplifv the surgical procedure ’
INJECTION OF OPAQVE FLUID (UTEROSALPINGOCRAPHY;
The injection of a fluid opaque to X mj** folloued tbc method devised bv
of inflation of the uterus and Fallopian tulies b^ gas man) aiiflion
ties it is claimed that it is superior to inflation inth gas in that it slions
(1) The outline of the uterine cnait)
(2) The length shape and di'*po9ition of the tubes
(3) The patcnc) of one or both tubes
(4) If either tube is ol stmeted the site of obstruction
(5) Rlicn Uaed \uth an initial ptritonea! inflation the relationship of the
uterus and tulics to a neoplasm
Owing to the fact that when the tubes are patent, part of the fluid b
retained lu the jicntoncal caa lU it is necessarj that the medium shall lie non
toxic lor tills rcison Itpioilol or lodipm is usctl These substances arc
opiquc to \ n\8 ore non toxic and are gradual!) absorlicd when retained
in the tubes and jioritoiieal cants uallioiit an) ill elTects
Tf howcacr tlie distal end of t lit tube l>c occlmlcd or if the oil passes into a
potktt or jvickcfs due to pcritoneil adhesions it ma) liecome enc)’stcd and
lie remoiable onh hi ojiomtuc interference
Contraindications — The Riime contniimUcations nppl) to utcrosalpingo
pmpfis na are eiiunieratetl under transutcnnC inflalmn h) air
Technique — In this case it is necessnr) to make the injection of the fluid,
M7 lipiodol, uatli the pitieiit in the lithotomy position on the I’olter Buck'
table The uTitcrs liare not u ed an) special apparatus bc)ond a lOec
Record 8)riiigc fitted on the end of n Rubm 8 cnimiila A sjiecial apparatus
has lieen designed similar to that for injection of g-is, b) uhicli the pre-.surens
well as tlie lolume mas be estimated
The pitient s biittocl s art biouglit to tht end of the table, and a siiecii’uni
IS luscrtcil into the sagina The cctmx wgTuajxMl "ith xolselluin forccyis and
afttr Rwabhiiig a fcound is inserted to gi'c the hngtii and direction of tlic
ca\it\ of tlic uterus The ranniila is then inserted and aolselia are reflxed to
tri to form a enug fluid tight joint l»etuccu the coraix and the rublier acorn on
the tube
Iht patient is thtn moved Imck into jiosition over tbo I’ottcr Bucks dia
pliragm carcfulh without displaiiii,^ the tulie in the utenis the legs licmg gi ntlv
lowcnd so that tlio jiatniit hes aupine uith tho legs extended
The film is then put m the earner ami all jinp 'rations arc made for taking
the radiogram I'oforc tin. injection !■* htartwl 'I lie imfers ha'o not madi a
X RAYS IX GYXXCOLOGY
371
practice of Matching the injection Mitfa a fivwrescent screen hut aim at taking
the first radiogram when the cavity of the ntenis is distended The patient is
siieciallj warned not to move but to cry ** Oh ! * u hen she feels anj pam She
has discomfort with the presence of the tube m the uterus, but as the oil'is
2 *j — UtoTcsnl] insozmilij after injection of 4 cc lipio<lol into utenw
sJoul} injccteil to fill the utcni* it eauscs pain, and her cri la the signal to
take the radiogram (Fig 23"») (or preferably a pair of stcreo<!eopic radiograms)
The amount nccc'aarj to achieve this \anes m dificrcnt subjects hut is usually
al)out 3-4 c c
ihrt U}.h tlic cer\ i< I'* \en npt to occur and to bjioiI the jiictiirc-s if the scries of
mdiopmms i» not taken qmcklj )
III 1} e radiO|.rams the oulhiie f r the utenm cacit^ jsreadih wen lh"»t of
tl e tulK“s tlcjicnds ( n the conditions present
CY\/rCOTOG\
373
Diagnostic Applications
— In the ei^e of norvml (ubcs
(Fig 2o7) lipiodol IS seen in
the inajontj of ca'^cs to he
present in small <lro|te lu the
pouch of Doughs or m the
neighbourhood of the fun
brnl ends In occluf^ion of
thufimbnnl end tliere iui\ lie
shomi 1 bulljou-. outline
according to the condition of
the tube nith ab'>encc of
drops in the peritoneal
caMh In offhision 0 / tie
«fen lie CM<I t here i-} of course
no hpiodol in the tube and
tonsequentli no shadon on
the affected "ido (Itg 2 jS)
hen the tidies become filled
with hpiodol their sliaiie
length and disjxi ition arc
readili disclo ed whether
patent into the iientoneum
or not
It IS strongU recom
mended that further filing
lie taken after twentj four
and fort\ -eight hours m
order to confirm in a po«iti>c
case orsiihstantiate oriicga
tne m a douhtful case the
pas. age of oil through the
tidie 111 the ca.«e of ixitcucfi
of one or both tubes the c
later radiogram-? a%iU show*
the presence of hpiodol in
streaks (I ig 2»*i) resembling
rpplcs of sand on the
seashort m the cantj of the
l>cl\is This IS caused h\
the iipiodol draining out of
the tulles into the pel\LS
« here it gprt id-* out bctvrecn
1-1 Ui^nnalpuiiioimim Nonnal Gallop an tubes
Dro] I (s m pouci At Do i,IaH
374
riniALE GEMTAL TRACT
the coils of bov'cl , that m the uterus drains out of the ccrv i\ into the \ agina
ftiul IS usinllj not seen m the later radiograms Emphasis should bo placed
on the necf’sitj for taking n radiogram on the day follow mg the injection,
as not mfrequenth hpiodo! is. then found in the peritoneal cavitj (Fig 2C1)
in ca'Os in which from the earlier radiograms the tubes appear to be
occluded (Fig 2C0) The non passage of the lipiodol through the fimbriated
1 lo iS — t torcMilf iiu.ry,triiin ^ line palipni iw tie ra 1 c4,rani 24 liourn after ujjwtion
ofl j lo 1 ! into utonj-i \olp now KluuiownoDi] to lol tn pcritononl ra»
ends of the Fallopian tulics at the time of the injection is presumabl} due
to pjasni uhiili later relaxes and allows the Itpiodol to piss into the
jicntoiieil caMti ginng nso to the charvctenstie wait like shadows
rcfomtl to
Droplets of oil seen oul*ide the tulic indicntt patenej of the tube but
if m the liter nidiograms (iicxl dn\) tlie^ baie failed to spreatl out to
fonn the t lianuttnstn. wave like shadows indicatlic of free hpiodol m the
.>1 the iK»s>ibihtj of a isnllcd in jientoiical pricket must bo
370
FEIMALE GENITAL TRACT
considtrecl (I'lg 202) Droplets of oil a dilated tulie will indicate tie
pnxncc of hydrofalpiiix
Tlie pie^enTO of a bifornmle uterus (Fig 203) is readilv demonstrated bj
uterosalpmgogniplij with lotli'^d oil
Utt^exion and ntrojltzion ate best demonstrated in lateral radiogram®
after injection of iodi'<*d oil
In the event of the uterine cavitj slioaiiig a filling defect or defect® the
pro^'Cnce of inters/WioI or #Hfc»itifo«« ^broids or of corciaoina tifm is sviggc-sted
1 1 < l ttn»alpi»L >!rram oil tn wnllod m | eritcti*^! f>o> k< t
In the ca«c uf (ibniid® the fiiliiig-defect is tiMialh sinnoth while in rartinonn it
IS mon* hkcli to 1>c ragged iii ivmtoiir
If a small ptihp or «ubmiieuus fibroid be prevent, especially on the anterior
or jMifttnur wall it rna\ Ik? obseuml if the uterus lie distendefl In lipiodol
For this n.n®on a radiogram is adi isable lieforo the uterus is fully distcndeil
\\ hen. i>t>sMlile a control of the degree of filling h ndn'ible by fiiioro->coiii ,
tluiiigh the wnttrs have not done this lui a routine
T iii> Uiir. rr.nnoi .i.ncTM..^!^ an eoflif pregnancy from a single fil/tvid is often
\RA\S GYls^OLOGy
377
one of difiiculU According to llernstetn failure of the oil to enter the
1 allopmn tubes m sucli n c'lfc is a point m favour of p^egnanc^ He states
that early closure of the cornua is the rule in pregnanct irrespocti\e of the site
of attachment of the o\um
*’03 — 1. leiv'alf lnf^o^.'ruIn •^hon > ^ b ron uate I 0 /jp lube filed Nole
fill i, Uererti <1 e to buI n fbro l<
It should be noted howoer that fibroids in the region of the cornua may
pre\cut filling of one or both till
\\ here an rcfopic pre/jnancf/ is suspected and the cbagiiosis cannot be estab
lishcd either In clinical means or b> direct radiograpln uterosalpmgographj
maj lie of \alue If it is found that Ixith tubes are permeable ectopic preg
iiancj ma\ be evcltulcd If one tiilKs be permeable and the other dilated and
378
FEM^E GEXma TRACT
parth or completely obstructetl, with a flnt or rounded filling defect at the
obstructed end, an ectopic j>rr(/na«cy should be suspected
In the case of extrautonne tumours, such as otcinan or tnlraligatnenloua
cysts or dcrmouls or o? peJuncvlatid fibromata, the uterine shadow will showa
dispHcement laterally or nntero posteriorly away from the tumour, the shadow
of the uterine tmity being otherwise normal The Fallopian tube also will
show elongation and di-ijilcu-cmcnt b\ the tumour (Fig 201), o'vcr which it may
be strt tched
If there H doubt as to the n-Jattoiiship to the uterus of a fcctus shown by
dinct radioprapby, the qiicbtion enn be settled by demonstrating the jwjifiou
and shape of the utenne cimIj In uterosalpingography Such n pniccdar®
«Iiould not l>o oiloptcd however, unless the termination of the pregnancy is
in any case desirable (Fig 263)
X-RAYS IX GYX^COLOGY
COMBINATION OF PERITONEAL INFLATION AND PER TUBAL
INJECTION WITH LIPIODOL
Tlic \vnters liave no cxpenenco of this method It is recommended by
Stem and Arens particularly m cases of a tumour or tumours m the pelvis, in
uhich it IS required to difTcr-
entjate the uterus and tubes i ■
Tlie iientonevm must be |
inflated Muth gas first , the
hpiodol IS then injected and
the film taken inth the
patient m the Trendelenburg
position, as in n simple gas
inflation
According to Jarcho (\^bo
shows several illu«trati\e
radiograms) the combination
of the two methods is uuli
Cfttod when additional mfor-
Illation, not obtainable bj
either nictliod alone, is dc
sired When successful, it
enables the clmicnn to map
out normal and abnormal
states of the pelvic viscera
Prcquently neoplasms of the
uterus and adne\a are clearly
demonstrated The method
Fio — LipiOfloIujjocfwhntouteru^ An«vJarprt?{mftncj-
al«o shows distmcth the sphincters at the proximal end of the inter&titial
iKirtion of the Fallopian tubes
Its maximum utility appears to be in the nsuahsation of vierme fibroids and
of m-arioii cysts, their relation to the uterine cavity being clearlj demonstrated
BinLiooPwipni
BtcLtrt, C, “ 1 Exploration Itadiolc^qac en Gvnecologie ’ Pari«. 1D2S
IlECSEit C. Semana 3M, l‘»24, II, 1400
jArciio, J , “ Gviiiicological Bcentgenolopy, Annnt* 0 / J‘rrnt , XJII, 77 , Ibid , 17ti-90 ,
Ibid , 3SS
KI:^^tl>T. W T. <7 Jmer Med Jfs, JW3 LXXXV, 13
C.J Jmer iled A«* . 1020, LXXIV. 1017
Srm. I F, ami Ants*, R A,J Jmer Med Ate , IQ2G. hXXXVll, 1209
PART mVL
OBSTETRICS
R E ROBERTS, II D , B So , D P H , E F R , D M R E
PART FlVi:
OBSTETRICS
CHAPTER \i.XI
GENERAL TECHNIQUE
Ijie E\OLimo\ of radiologj m obstetrics has been compar'iti\cly slo^ In
earlier times workers were Inndicappod bj bnntations in the power of apparatus
it being impossible to produce currents of sufficient intensitj and kilovoltage
to penetrate satisfactorily the relatively opaque liquor amiin and to cut down
the length of the exposure to a degree m uhich the motihQ of the feetus and
the respiratory movements of the mother could be ebmmatcd >jowaday8
however with apparatus having a laige output of energy hot cathode tubes
capiblo of carrying large currents the Potter Bucky diaphragm by which
secomlarj radiations are largelv eliminated immobilising apphances and ultra
rapid films and intensifying screens the technical difficulties encountered by
earlier workers have to a great extent disappeared Satisfactory radiograms
of the gnvad uterus can now he obtains! readily in from two to six «coonds
TECHNIQUE OF EXAMINATION
Even With the most efficient apjmratus special attention must be paid to
technique if uniformly satisfactory radiograms are to be obtained
Apparatus and Accessones — A modem high tension transformer should be
u<.cd witli allot cathode tube an efficient Potter Buckv diaphragm fitted with a
compressor hand and rapid speed double coate<} films and intensify ing screens
Kilovoltage — ^The quality of \ rays used must be such that they will
penetrate the opaque liquor ammi but wall not over penetrate the developing
fcDtal bony parts In the earlier stages of pregnancy and w hen the patient is
thmandthcreisnoe\ces.sofliquorammi akilovoltngeof GOtoGoKI P wnllbe
sufiicienf In the later stages of pixgnancy or v\ hen the patient s girth is large
(cspocmlly ifthiffbodiietohydrammos) kilovoltages upto 100K\ P may be
necc sarj A filter of I-S mm aluminium liclow the \ ray tiiljo is advisable
Current — A current of 50 A[ A or npwartls should lie employ ed in order to
cut down the time of exposure to a minimum
Focus film Distance — If the distance lictween the target of the X ray
tul)o and tlu film lie small the exposvire will !« cut down but owing to the
dnerr^nce of tl e nvvi> tl ero will be produced on the film a lack of definition and
a disproportion Ixitw con the fcctal and maternal parts w Inch mav be misleading
3S4
OBSTLTIUCS
If i\ “ focws film {listnnce be great the dispTOi»ortion will bo loss b«t the tiine
of exposure «ill need to bo incrcasotl to a degree vhen fcctil and xnaterml
mo\cinents itin\ occur witli resultant blurring of the image
A routine working distance of 30 mebes between the target and film is
tlierefoix recommended as n satisfacton compmmi e I\hate\cr working
distance be decided upon it is adrisable to keep it constant for all ca'cs in
order that the lesultant radiographic si/cs iinv be comparable
Exposure — This wall depend on the inilliamperagc used the speed of the
films and inlcnsifjing bcreens and the distance of the tube from the film
tOjjCfher with the thickness of tho j>art to be mdiogrxphed
The shorter the exposure tlio le^s risk is there of the film being spoilt bj
fcctal or maternal moxemenls With suitable appiratus and accc'^sonca
batisfactorj radiograms at a focus film distance of 30 inches blioiild Ik* oh
lamed m a pititnt of moderate bi^e in almut two seconds in no case should
the cxposuip exceed six setomU— otherwise bltinmg of tiic fcctal or rantemal
moxement is practicallx mexitnble (this does not of course applx to pcln
nictrj when tho fcctal imago is of secondari importanc-o)
Position of Patient — ft is usuallj adiisable to tale radiograms m the
8upme prone and latcial positions (right or left iiccorflmg to the position of
the fatus) Occnsionallx an oblique xicn is ndvisible to tluow the sliadoir
of the fatal bom parts awax from the tnalenial skeletal sliaclows
In tho pione position it max Ik. desirable in some cases to relieve tho
pressure on the alidomen b\ supporting the thighs on a pillow if neeessarj
also tho ]iatient ma^ bo allowed to rest the thorax fiiml> on the elbows xnth
the arms eroded under the chest but out of the waj of the abdomen TIiO
chief adxantagCh of tlic prone po->ilion are that this position m most ca®es hrmgs
the fcotus nearer the film and olso immobilises it better resulting in clearer
definition of the fatal parts
The adxantnges of the lateral x lew ircthntilgixesinloTinationrelatmi-tothe
position of the fcetal spine (anterior or iHjslcnoi) and that the fatal limb shadows
are more likolx to lie sliown cl<‘nror those of the maternal spine On this account
os.>.ific centres in the fmtus can often lie showai more readilj in this position than
in the prone or supine position I>atcral radiograms in tho erect position are
of special xahie in patients with jK-ndiilous abdomens where information is re
quiitd regarding the inclination of the i>elxic bnm to the axis of tho lumbarspine
— in siicii exainmationsaxcrtKal Potter Biicki diaphragm is of course required
The lateral xicw centred oxer the brim of tho i>elxis al'o gixes xaluable
information as to the plane of the bnm the lunibo sacral angle tlie Fliajic and
plane of the anterior surface of the fcaerum the inclination of the posterior sur
face of the 8j mphxsis pubis and the relation of the fcctal bead to the siqwnor
strut of thcpclxns It also gtxes ft read) menns of confirming themensiircmcnt
of the conjugate diameter of the bnm ns estimated bv other pclximctnc
GENERAL TECHNIQUE
385
In the Bupinc position espeeiallj if there be lordosis it is often helpful to
put a pillou beneath the knees of the patient this gives a greater sense of
comfort to the mother and brings her ^inc nearer to the film bj flattening out
the lumbar curve
Immobilisation of the Fmtus — ^This. is helped bv the use of a compressor
hand the latter should hov\ ever not be pulled too tightlj otheruase increased
fcetal activity instead of immobilisation will be the result
Suppression of Maternal Respiratory Movement — Owing to the presence in
the ahdomcn of the enlarged uterus the pregnant w oman finds it more difhcult
to hold her breatli than the non pregnant patient It is however essential
that during the exposure there shall be no respiratory movement The readiest
means of bnngmg tius about is to make the patient after a few prehmmarj
respirations hold her nose and close her bps at the point of deep expu’ation
iVfter a httle practice most patients can by this means be persuaded to suppress
their respiration for the reqmsite penod of time during the making of the
exposure Obviouslj the shorter tho exiiosure the better the result in tins
respect Exiierienco shows that there is a better chance of complete immo
bihty on the part of the diaphragm m expiration than in inspiration
\ senes of at least three radiograms (supine prone and lateral) now
having been taken our next consideration is the information that may be
obtained from them
INFORMATION AVAILABLE FROM RADIOGRAPHIC EXAMINATION
Information on the folloinng points may be available from an inspection
of the radiograms
(1) The positiv c diagnosis of pregnancy or m a case of an obacure swelhng
the differential diagnosis between pregnancy ond a pelvic tumour
(2) Tjje presence or absence of any gross inatemal deformity (lesser degrees
of deformity are demonstrable by means of radiological pelvimetry to be
described later)
(3) The approximate indication of the age of tlie fcotus
(4) Tlie position and presentation of the fcctus the position of its limbs
xi.P.d I.be jyt? .IwjmJ
(5) Tlie existence or otherwise of any disproportion between tlie festal
head and the maternal pelvas
(C) The cau<!e of hydraranios wath special reference to multiple preg
nancy and fcctal abnormalities
(7) Intrauterine death of tlio feetus
(8) Occasionally evadence of estmutenno pregnancy
X R II — 26
CHAPTER XXXII
DIAGNOSIS or PREGN*.\NC\ AKD ALATERXAL PELVIC DEFORSmiES
X-RAY DIACKOSIS OF PREGNANCY
SrsCE TiiE advent of the Zondek Wlieim test the early diagnosis of pregnnncv
bj radiolog\ vs of It's importance than preMoU 8 l 5
The ndiological diagnosis is honc\er an immediate one, whereas the
Zondek Ascheim test take^ a feu dajs for its completion The radiological
examination is particularly apphc'iblc m «i«es of suspected illegitimate preg
nancy wlicre ob\ lous difficulties max anse in pcrfoniung a clinical examination
Diagnosis by Direct Radiography — Owing to the relitixely' poor calcium
content of the fcctal skeleton in the early stages of pregnancy , it is not possible,
cten mth the most careful technique to demonstrate fcctal bony parts before
the thirteenth week As a rule consistent demonstration of fcctal jiarts is not
]>os«ibIe till aliout the sixteenth to tnenticth week The film must he of good
quality and the shadows of the maternal Iwn' parts ibslodged from the uterine
area ns mneh ns po-siblo For this purpose the prone iwsition mav bo used
with the ttilie tilted slighth towanls the lieid or the supine po«ition with tlie
tube tilted slightly touards the feet ^metimcs a slightly oblique position of
the raothtr 6 jiclns m relation to the central ray is also of ad\antage
In the pchic nrea the shadows to be searched for are one or more of the
following (Figs 2flG 2C7)
(a) The crescentic or annular shadows of the fmtal skull
{h) The bended shadow of the fcptil spine
(c) 'Ihc ladilcr like shadow of the fcetnl nbs
(rf) 'Ihe linear shallow of one or more of the fnjtal limb bones
Before excluding the presence of n fretus at least three good radjograma
Bhould gi\e negative results In cases of doubt the examination should I*
rcix-nted after an iiiteraa! of one or two weeks Care should of course,
taken tochminatt rectal or \esicol shadow sin cnicient preliminary preparation
At or after the sixteenth week it should be possible to exclude prepianty
defmitciv by radiographic means Tlio differential diagnosis of pregnancy
from Ai/f/fl/idi/om mole ulcniie or o/Arr pe/t ic /uwiomm should be thus rcndcreil
definite
Diagnosis by Ihe Use of Contrast Media — By injecting lipiodol into the
iitcmie c-iMty //ciwcr bad l»ecn able todemonstmU as early as one week after
conreption the presence of the ox-um as a filling defect in the ojxaque medium
The employment of this methoii liowcxcr is indicated onlv in eases where a
PREGNA^CY AKD itATER^AL PEOTC DEFORMTHf;? t 3S7
tennin'ition of pregnanej ifpresent ^ould be desirable there is a gra\ e riak
of the oil, ^\hen injected into the uterine cavitj producing abortion A
submucous polyp if present might produce a filhng-defect which would bt
indistinguishable from that of an ovum
R 3 the method of transabdoniinal pneumopentoneura Peterson has been able
tio "rr — Th rt<?cr» reeks f«l w nhowinc I n»b bonc^* «pine on I nl«
todia„na«eutcnneen!argcmcntiiidicativeofpregnanc\ ascarh as thesixthucek
Howe\er JIen}Klein states that m cases of pregnanej the cornua c!o'«e
carl^ so that a rounded filling defect in the uterine ca\it\ combined ivith non
filling of the 1 nllopnn tul>cs is pre*»umptiie e\i<Ience of pregnancy rather than
of fibroids ('»ce p 377)
3S3
OBSTETRICS
claims to lia\c demonstrated bj intra\enous injection of 2 grms of
htrontnim bromide m a 10 per cent solution linlf an hour Ixifore radiogmphj, a
tuo months pregnnncj as a rclatneh translucent area in the liquor amnii
(uluch Ins l>cen made more ojwique In e\cretion of the dje) He also claims
to be able to differentiate lietueen pregnaiic\ and a ntenne fibroid bj this
[ ^ J
tir ■*C” — f) xipen fust < «l «rinv «kul] nlw an I I ml bonM
nietho<l the uterus m pregnano shownng a clear-cut outline as opposctl to the
fluffy sliadow of fibroids llisuork liowescr lacks confirmation
CHANCES IN THE PELVIC JOINTS DURING PREGNANCY
Duniip pregnancy the pymphysis pubis and to a less extent the ancro
lime joints incrca>e in width Ry applying the ajiprojinate correction factors
PREGNANCY AND JIATERNAL PELVIC DEFORMITIES 38(
to compensate for the distance of these joints from the film Hoberls estimat
the true \ndth of the symphisis pubis and sacro iliac joints m the senes
pregnant and non pregnant women He found the a\erage “ mean ” width
the symphjsis pubis m nulhpirous ivomen to be 2 G mm , durmg pregnan
this increaserl to 4 5 mm During parturition he found that any further mcrea
in width was verj’ alight and that withm a few months after parturition t
width usually returned to its pre pregnant measurement In multiparo
women the mcreaso in width during pregnancy was shghtly greater than
pnmigravid'B, the average width in pregnant multiparie being S mm
ijo — ^Di-ilocntion of •yln[>l>^9H pubis foHowin? riiflitult Idboiir
opposed to the pnmigraridous average widtli of 4 5 mm The nmximui
width seen in his senes was 10 mm
In pregnant cases with » wide symphjsis lie was able to demonsfrat
radjologically a vertical or gliding movement of the pubic bones on each othe:
when tlie weight of the body was transferred from one foot to the other
Tlie sacro line joint likewise widens slightly during iirognanej Th
average aggregate width of the two sacro iliac joints in milhparous uonien wa
found to be 3 fl mm In pHraigraMduit merensed to 4 3 mm , while the sani
measurement was recorded for multipart After parturition the averag
w idth of the joints w as found to return to 3 9 mm , i c almost, but not quite, ti
its pro pregnant width
390
OBSTEIBICS
\8 ft result of difiicult labour with or mtliout the application of forceps
traumatic rupture or dislocation of the simphjsis pubis sometimes occurs
(Fig 208) Occftsionallj fractures through the pubic and isclual rami may
occur
Nonnallj however the foetal si all gi%cs way to the pressure more readily
than tlic firmer maternal bony pelvis \nth the result that radiograms taken
dunng parturition show a greater or less degree of moulding of the bones
of the raidt ■which ma\ o\emde each other to n marked degree (Fig 302)
MATERNAL PELVIC DEFORMITIES
Gro's pehie deformities anil be usually demonstrated m a single raibo
gram in tbe supine position amplified aibere necessary bv stereoscopic radio
gmnis in either the supine or prone position and/or by a lateral new ^Imor
deformities however may need a more Accurate in% cstigation by means of
radiologital i>ehirnetry
\iu deformity of the matonial spine or pelvis winch may give rise to difBciiIt
labour is of importance to the obstetrical radiologist As however the \ ray
nppeaionccs associated with the various conditions which may result in such
deformities have V»ecn desenbed elsewhere m this book no useful purpose wall
Ic served by their rcitenition It may however be of scrv icc to the nuliologiat
if their ob tetneal classification be recalled at this juncture The follovnng
il isfiification by Sclaula intxhficd by Dougil will probably bo found the most
HUitablo
A CoNarsrrvr ABNORvivLtrits
(rt) f enerallj contneted {xjUis
(6) Smiilo flat pelvis
(f) Assimilation pelvis
(d) ^n?J,clc pelvis
(e) llolicrts pelvis
(/) Generally cnlargi-d pelvis
(?) ^pht pelvis
B \cQi niro A^^oI;M\L^^Es
(1) Dneate or Ii junj of ihe Pehtc Bones
(0) Rickets (i) Rachitic flat pelvis
(u) Rachitic flat and generally contractctl jielvis
(ill) Irregularly contracted rachitic {lelvas
(6) Osteomalacia — osteom ilaiic pelvis
(c) New prowilia
( 1) 1 ractiirc
(c) Vtropliv canes ncerosw
PREGNANCY AND MATERNAL PELVIC DEFORMITIES 301
(2) Di$ease or Injury of the, Pelmc Joints
(a) SjTiosfosis of the pelvic symplijais
(b) Synostosis of one or botli sacro iliac joints
(c) SjTiostosjs of sacro coccygeal joint
(d) Exaggerated movement or separation of pelvic joints
(3) Disease or Injury of the 1 ertebrte
(o) Scoliosis
(6) Kyphosis
(c) Ivj'po scoliosis
(d) Lortlosis
(c) SpondjloUsthesis
(4) Disease or Injury of the Htp Joints or Loiur Limbs
(o) Coxitis
(6) Luxation of the head of one or both femora
(c) Absence or deformitj of one or both lower extremities
CHAPTER X\XIII
lUDIOLOGlCVL PEUDIETRY
iiiLST CORDIALLY ogreemg with the axiom that the best pelnmeter is the
foDtal head one finds that ob$tetnams are not infrequently faced with ca^s
in which the relative size of the fostal head and of the pehne inlet cannot bo
^.nut>ed bv clinical means In such ca'ses radiologj raij be called on to plaj
in important part in accurately assc'ising the diameters of the pelvic bnm or
I f the outlet
It 13 obnous that the le^s ti'isiie the \ m\8 have to penetrate {i e the earher
in the pregnancy ) the clearer mil be the ndiograms unfortunately the patient
H often allowed to go almost to full term before the radiologist is asked to
in' estimate 1 er pelvic measurements
RADIOLOGICAL PELVIMETRY OF THE INLET
Among the methods more commonly emploved in this country for esti
mating the dmmetora of tiie bnm b\ radiological means may bo mentioned
the following
Methods of Thoms Roberts and Rowden — In each of these methods tie
bnm of the pelvis is placed horizontally and parallel to the \ ray film and the
central \ ray is made to pass rcrticalK through its centre tho radiogram so
obtained is a Rrmmetricnlly cniargcil picture of the pelvic bnm (Fig SG'J)
without any of the foreshortening seen in the usual supine or prone
mdiograin*
Technique of Thoms' Method of Pelvimetry — ^The patient is placed m the
pitting position (onginnlly described by Albert) on tho middle of the Potter
Bitcky diaphragm her shoulders liciiig supported by an adjustable back rest
The YKitient and back rest arc manipufatcd tiU the pelvic bnm is honzontal
1 c pirillel to the film on tlic Potter Bu^y tm^ Tlus is attained by means of
a cillnier one foot of which is placed in contact with the upper liorderof the
%VVAY^.v,iAs, yM.b’* V.w cAVin fvsA w to twA'&rt.'RAk tV* k/KM bw-bic
of the spmc of the fourtli lumbar \ertcbm (ibo latter point is sitxntcd about an
inch alnn e the line joining the postenor t-upenor spines of the ilmc bones felt
in dimple's on each fuIc of the middle line)
The patient haiing been placoil ccntrallv o\er the film in this position and
leaning firmh against tho back rest (n)uch will bo about 55" 60® from tic
honzontal} the \ ro\ tube is placed so that its focal spot is sertically altoio
the middle of the pchic brim (approvimatels 2 inches Ixrhmd the upjwr border
35 ’
RADIOLOGICAL RELATlilETRY
393
of the sjTiiphy^is puhis) The tube is then rai'^ed or lowered till its target is
30 inches ^ ertically abo\e the film
Tiie radiogram is now taken and the rerticil height of the upper border of
the 83^nph^sl3 {corresponding to the horizontal plane of the pelvic bnm) is
measured Thepatientisnowremovedfromthetable the tube and film being
left m position
A perforated metal sheet (in w hich small holes have been punched at the
points of intersection of lines draun at right angles I cm apart) is now snb
stituted at the height previously occupied by the patient s peine bnm and a
Fio 269 •—Rail ogram tn Mtt ns; ponton with pehtc bnm placeil honznntall}
short exposure of one to tw o seconds is made The jierforations in the metal
sheet show on the film as black dots these dots on the film are slightly more
than 1 cm apart according to the lieight of the sheet above the film The
length of the diameters can now be. measured directly on the film (m
centimetres) from this faUe centimetre scale produced by the dots
Technique of Roberts’ Method of Pelvimetry — In tins method the position
of the patient tube and film are as in TAom-s method (i e the patient sits on
the Potter Bucky diaphragm with the pelvic brim honzontal her back being
supported by an adjustable back rest and her head kept extended so ns to bo
at a safe distance from the tube the tube being rotated «o that its projecting
arms arc across the long axis of the tabic The tube is centred 30 inches
vcrticallv nbo\ ( the centre of the bnm {2 inclics behind the vertical plane of the
syrophvsjs — c«tinMted more accuratelv if desired, by means of n plumb
394
OBSTETRICS
Irab — hanging do\m beneatii the centre of the filter in the diaphragm of the
tube bos) (Fig 270)
Uie radiogram is now taken , an esposurc of five to twelve seconds is
usually sufficient with an efficient apparatus (10 K transformer, hot-
cathode tube passing 60 JI A at 100 to 120 K V P ) , tins exposure may need
to bo increased in a bulkj* or advancetUy pregnant patient
A radiogram of more even densitv is obtained if the “ liatthet ” described
lia 170 — Posicioii of {atimt in raothml of ra<lioloRicol ppUiniifry Bj 0^
iho iwUk t>nm w {ttralM ic* «Ijp IUto omi an ■onUaVotlwl Miiifonnij inlarp'^J
r?! re'ontolion of tlio bnm n obtaincil from iIk? iwliogrotn all Iht. ilinmolct** ina\ lio mufly
anil lucurntplv (><limiitnl
m Jlwalens mctlioil (see later) is cinplo^id , tins prevents the relative over
exposure of the anterior ]>ortion of the bnm which otherwise takes place
Immcdisttli after the radiogram lias ticen taken and without moving t'lic
jvaticnt the following menswromcnts are mmlc
(1) The vertical height of the nnticatlioflo above the upper bonier of the
sjmphvsLs piiliis (hj a tape nicasiirc) or altcmntivelj tlio vertical height of
the top of the s} niphjsis above the fiJm (hv ruler)
(Instead of lueasunng the tiilic bv iiiphj sis distance it will probah!> ho
found envier to incasiiro the symphjBis film height TJic simplest waj of
doing tins is to il^c an onlinaiy wootlen ruler fniin the bottom of which a
RADIOLOGICAL PELVIMETRY
395
Jength has been chopped off equal to the vertical
distance between the surface of the middle of the
Potter Backy table and the film This distance is
readily measured by placing a strong lath transverselj
across the top of the table and measimng the Vertical
lieight of this above the middle of the table and
above the film respectively , the difference between
these two measurements is the distance between the
film and the top of the table and is the amount « hich
must be chopped off from the end of the ruler It
must be measured accurately, otherwise an error will
be mtroduced into all future estimates of peine
measurements based on tins technique In the
curved topped Potter Bucky table used by the author
it IS IJ inches It will ^a^y inth different tables
and (hfferent types of cas^settes )
(2) The vertical height of the anticathode abo^e
the film (a standard tube film height of 30 inches is
suitable, with suitable apparatus this may inth
advantage be uicrca«ed to 40 inches)
It IS easy to estimate the true diameters of the
pelvic brim from those on the film by employing the
geometric principle illustrated in Fig 271
To obnate the necessity for tlic<»e geometneal
calculations tables hai e been prepared from which one
can obtain at a glance the correctetl or true measure
ment of aiij diameter from tbe corresponding film
measureinent (Tables 1 and 2)
Thus if when using the 30 inch tube fibn distance
the tube s^Tuplij^is height be 24| inches (le
symphjsis film height 6i inches) and the measure
mont on the film of the transverse diameter Ixi
t>| }nche9, then the true ronsurement of
the trans\erse diameter is seen from the table to be
A
J-/0 27J
A m target of tul^
DE reqtiirecl dHtmeter
of pelvic brim
FO corresponding dia
meter of brim as
meaMuml on film
AB B height of tube
utove fjrmph>8ia
pubM
AO B height of tube above
aim
DE AD
iO - AC
DL - FG ^
I e True chametcr =
film (Immetcr multi
pi wi b\ correction fac
5 1 inches Similarly for any other measurement
Similar tables niaj be prepared for any tube film distance other than
tho standards used here Obviously, the greater the tulxi film distance, tbe
smaller tbe margin of error Man} workers ore, howe\er, limited in their
Working dj>»tance, either b> the output of their plant or the tjqie of Potter-
Ihick\ table available
Estimation of the Measurement of the Conjugate from Lateral View of
Pelvis — In the event of a patient having spinal or hip disease, it innj l>e im-
possible so to jKi^ture the patient that t? — -
39G
OBSTETRICS
RADIOLOGIC \I PLLA’niETR\ CORRFCTION* TAHLIS
TaIILF I — TcSF FILM HElOIfT = 30 I\CHr«
Ucuarcnifst on FUo
j Trtii or Coirerted Jlessurrmfnt.
4 inches
1 32 !
33
33 '
1 3 4 me! es
1 34
3 5
35 i
j 3 6
3fl
37
7 ■
3 8
38
39
1 3 9
40
40
4 t
4 I
4 2
4
43
: 4 4
4 7
1}
4 4
45
4 ft
4 7
d
4 0
47
4 8
49
11
48
4 n '
50
5 1
'U
SO
5 1
S3
«)
57
o4
55
Cl j
54
5 7
76
57
Tube fn-nar lii-ii hei>,lit (inclic«) '
>1
211
2.
J
Snnphvsu film height (inci «>4)
ft
71
41
Tadij- 2 — Ubfre TtoFmjt IIeiciit - -JO Inchf^
Jf a<ii/tnii-at «n Film Tnie f«f Ccrtfflul M a*urniiriit
4 iticl e«
1 34
35
1 5 7 inrl w
•»!
70
3 7
37 1
1 37
41
3ft
30
40 1
40
4}
40
4 1
4 2 1
42
4**
43
4 4
44
q
45
4 7
4 ft
4 7
51
4 *
4 8
40
71
49
4 0
>0
51
0
S 1
1 S!
5 2
53
<1
S3
1 54
5 '
«1
7fi
7 7
68
n
57
1 5ft
>0
6 0
Tulx* »>m{ tusis 1 e ghi (inrl c»)
71
1 711
37
3>i
»nph> m film hcicht (inci m)
0
71
41
m an oIk'^c or oflien\i«c uimlisfictorj jiaticnt it nmj Ixj desirable to confina
the conjugate measurenient as estimated liy the foregoing methoe! In ciscs
of i>cnduIoiH abdomen or when (lie fa.tal head oAcmdes the sjmph\sH piihts
It maj l>e difRcuU to measure the exact height of the sjmphjMS nlK»et^®
film or below the tuljt
In such cases the iiieasurcmt nt of the conjugate can lie rcadih estimated
frtjin ft lateral \itw of tlie jiehis Tlie patient is placed Ijing nccuratelj oo
RADIOLOGICAL PEL^^^rETRY
397
the side «50 that the conjugate diameter is honzontal (i e symphysia puhis at
the same height as the natal cleft or more accurately the spmous process of the
fourth linnhar vertebra)
Tlie tube IS centred vertically over the upper border of the greater tro
chanter at a height of 40 inches above the film The radiogram is taken and
theiertical distance betneen the symphysispubui and the target of the tube is
me isured (by a tape measure or ruler)
Tlie conjugate diameter (<listancc between the posterior surface of tlie upper
part of the symphysis and the anterior surface of the promontory) is measured
on the film From this it is quite easy to estimate the true conjugate ba
cmployang the principle of Fig 271
Technique of Rowden's Method of Pelvimetry
In this the patient la placed in the same position in relation to the film as
in Thorns' and Hobtris' motliod {Alberts position) and the tube again centred
vertically above the nuddle of the horizontally placed peinc brim The tube
film distance is however, greater than m TJtoms' and Jioberts methods, being
4 feet 6 inches , and a Sectognd Potter Bucky diaphragm takes tlie place of
the curved ty’jie The increased tube film distance diminishes the degree
of distortion produced on the film
To prevent relative over-exposure of the anterior portion of tho brim
or uiulor-oxposure of its posterior portion Bouden advocates tho use of a
“ hatchet ” Tina is a sheet of lead on a wooden handle, the uhole resembling
a spade with the distal portion cut out into a shght concavity After tho
anterior portion of the brim has received about twelve seconds’ exposure
(15 51 A at 120K V P ) this hatchet is placed horizontally against the patient’s
abdomen about the level of the umbilicus , tho exposure of the posterior
portion of the bnm is continued for a further twelve to thurty seconds
(according to the size of the patient’s nbilomen) By this means the resultant
radiogram is rendered of more oven density
In measuring the diameters, Hoicden uses the appropnatc one of a series of
“ pubic scales ” , these are prepared as follows
A Binp of fcad, cilieii a *‘rafe/ tsased,aboti6lSmchc!flonffandStci^c^
wide, supported by ply wood , tho lead strip has small holes drilled down the
centre exactly half an inch apart
From this “ rule ” the “ pubic scales ” (Fig 272) are made m the following
way The “ rule ” is sujiported horizontally over the Potter Bucky couch 41
inches above the surface, a film in a, cassette being placed in the usual position
The X ray tulic is centred 4 feet G inches above the film and a short exposure,
aliout a second, given The “ rule ” is then rai«cd a quarter of an inch and
another exposure is made on another film, and so on every quarter of an inch
up to (unche« The film's are dev doped and n number of pnnts are made from
each for stock, and each has its distinctive figure of height marked on it The
398
OBSTETRICS
spots on the scales thus pro
diiced represent half inches at
honzontal planes above the
surface of the Bucky couch
Technique of Hooton’s Method
of Pelvimetry
Fia 2T2 — Rawd'n’ft pubic Bcate In Hoolotl S lUCthod
antcro posterior and latcnl
films are taken mth the tube centred 14 incites above the os pubis
and just above the great trochanter respectively
Tlie thickness of the patient
from pvibis to couch (n) and her
evtrerae width across the tro
chanters (b) are then nitasurcd
Let the focus film distance he
28 inches (c) On tho antcro jkw
tenor film the transv erse diameter
IS niCASurod (d) and on the lateral
film the distance from the sacral
prornontorv to tho back of tho
os pubis (c)
The tnlciilation is as followh
d X (r — ?rt)
^ = tnic transverse X'cfUcot
diameter fiuler
c (r — \b)
- = tnie conjugate
c
diameter
Technique of Courtney Cage’s
Method of Pelvimetry
In Conrlnnj Cage r inethtHl
the patient occupies the semi
sitting po'-ilioii over the Jdni
the tnl)c 1 m mg centred over the
middle of the jiclric inlet a
plumb Imb hanging from the
centre of the filter and remaining j
m jw-ition during the exixwiire
A fpomt corresponding
fo hzighiof Xta'/tm)
Normal ray by
plumb bob
Aurinei
[wh-imotij
RADIOLOGICAL PELVDIETRY
399
of the film , tlu3 records on the film the point of incidence of the normal or
Tcrtical raj
The distances of the tube and of the top of the sjmphysis pubis from the film
are measured
After development, a tracing of the outhne of the pelvic inlet is made from
the dned radiogram, and a dot placed on the tracing at a point correspondmg
to the centre of the shadou of the plumb bob This tracing is pinned on to
the table
By means of a taut piece of elastic (AB) a plumb bob (AC) and a vertical
ruler (DE), used as in the illustration (Fig 273), the lines of the rajs irhich
have produced the image of the pelvic bnm are reproduced, the lower end (B)
of the elastic being moved round the tracing and the ruler bemg moved tiU the
point on it (F) corresponding to the height of the svmphysis pubis above the
film inleraeets the elastic
Bj markmg with a pened dots on the tracing at points correspondmg to the
ha«!e of the ruler (E) and joimng these dots an exact reproduction of the pelvic
hnin is obtained from vhich the various diameters are measured diicctlj
RADIOLOGICAL MEASURE-
MENT OF THE PELVIC
OUTLET
,a«Tm
ur
Transverse Diameter Chassard
and Lapme’s Method
The patient is placed
straddling a cassette containing
a 12* X 10' film , she is made
to stoop forward till the under
surface of the sj mphj sis pubis
anil the ischial tuberosities are
eqiiidLstantfromfhefilm 1 c the
puhic arch is now horizontal
The tube is centred verticallj
n’oo'veors’u^ittj postenortothe
ischial tulicrosities at a distance
of 30 Indies or more from the
film (Fig 274)
A TOihogram is now taV.cn
(about one to one and a Jialf
seconds will suffice with 30
AI A at 75 KVP) On the
radiogram (Fig 275) a lion
zonln) line is drairii to toucli
the surfaces of tlie isclual
Fic 274 ^Tof>itioa of patient film and tube m Oiu
sard antt lupine a mot! od of peU imcto of outlet
400
OBSrFTRICS
tuberoi'ilic^ A verticil line js tlraAtn from t!»e g}mpliy8is pubis to bisect
tills A second horizontal line is now drawn 1 cm nearer the Bymphjsis
pubis than the first one (to eompens'ite for enlargement due to distance of
bonj parts from the film) riie length of this line is approximateh the
measurement of the tmnsaerse diameter of the outlet (normally 4 inches)
From this ridio^rain tliere can aKo lie determined 1)> direct measurement
(1) riio angle of the pubic areh (normally 83*)
(2) llio height or depth of the pubic arch (normal!} about 2j inches)
tic 2"’>— llau prom of jeUi outl^ l> Cla>Manl nn I I^pn6s m thol All trans\en»o
tl amelcr of oull t teit)
Antero'posterlor Diameter of the Outlet (Posterior Portion)
Ana forward tilting of tlie Kicnim or cocejx will dimmish the antcro
posterior diameter of the outlet
TtcnNfQn — On the I’ottcr Buck} diaphragm the patient lies on her side
and thetulie is centred serticaTI} alios c flie iseliial tulicrosities (the position ol
the patient lx*ing adjusted till these are above the centre of the film) A
mdiograiii is now taken
The aerticnl dtstance of the tube from the film and from the natal cleft H
mcnsiired bj a tape iiicasuro and the appropnaic correction factor is estimated
Tlic film measurement of the distance between the back of the ischial tubir
ositics and the tip of the coccj x multiplusl bj this correction factor, is the true
mea.surt ment of the posterior jiart of the antcn> posterior ihamcter of the outlet
CHAPTER XXXIV
CEPHALOilETRY
THOMS’ METHOD OF CEPHALOMETRY
TfrE rniNciTLES involved in radiological pelwraetry can be employed in
favourable cases for an estimation of tbe size of tbe bead of tbe full term fcetus
m tifero The patient is placed m tbe supine position on the Potter-Bucljy
duiphngm The fcetal skull is then onentated by abdominal palpation , the
height of Its occipito frontal diameter above tbe film is measured by means of
caQipcrs, and tbe mclmation of tbe plane of this diameter to tbe honzontal is
noted A radiogram is then taken, with tbe tube centred at a measured
height above the film, over the middle of tbe foetal skull With the tube and
film still m positiorf the patient is remo\e<l ami a lead plate with perforations
1 cm apart is introduced in the same plane as that previously occupied bj the
occipito frontal diameter, and a further exposure made on the same film On
the film the space between the perforations will be enlarged in tbe '»ame pro
portion as the occipito frontal diameter The measurement of the latter can
therefore be directlj obtamed from the slightly magnified centimetre scale
formed by the perforation dots on the film
From an extrauterme study of l-IO fmtal heads winch Ind not been sub
jecte<l to moulding, Thoms constructed a table showing the relation of the
occipito'frontal diameter to the bipanctal diameter This is given herewith
Given an occipito frontal diameter of
12 5 cm subtract 2 5 cm for bipanetal diameter
120 ,
,, 2 5,, ,,
115 „
20 „ „
110 „
„ 1 75 „ „
10 5
.f 1 5 „
10 0 „
. 15 „ „
90 „
.. 15, ,
Cephalometrj is obviously most prcci>c when (he occipito-frontal diameter
lies exactly transversely, i e parallel to the film in the supine position of the
patient In such cases, if we measure the lieight of the occipito frontal dii-
meter above the film, and the height of the tube aboie the film, we can em-
ploy the perforated lead sljcct method of Thorns or the geometric principle of
floberM, to deduce the exact measurement of the occipito frontal diameter.,
\ n n — 20 401 -
402
OBSTETRICS
Having obtflineil the bipanctil diameter c'ln be estimated by reference to
2 homi’ table as given nbo\c
If lionever, the licnd is tilted shghtH, tlie ibnmeter slio«-n on the film mil
not be the tnic occipito frontal diameter, but uill be an oblique diameter
ROWDEN’S METHOD
Boinlcn advocates the taking of the cephalometric radiogram with the
patient sitting in the same position as for jielvnmctrj TJic cephalometnc and
pelvimctne measurements bj this means are available from the single radio
gram He employs standard cephalic scale strips for the cephalometric
estimations prepared in the same manner ns those for peUnmetrj the appro
priate scale being cliosen aecortling to the height of the centre of the fmtal
skull above the Aim (G to 0 inches with | inch intervals)
WALTONS METHOD
'llic patient is placed in tlic supine jnisilion wath the fcetal skull over the
centre of the Potter B«ck> diaphmgra
(1) A mark A is made on the anterior abdonunal violl over the centre
of the cliild s head
(2) A mark L h made on the lateral abdominal wall on the side
neorcst to and diroctl> opposite the centre of the thild s head
(3) An nntcro jKistcrior radiogram is taken centring the tube vertically
above the mark A The vertical heights of the tulx? and of the mark ‘ L ”
above the Aim arc measured
(4) \ I iteral radiogram is taken (with the Aim on the side nett to the mark
L ) centring the tube honroiitallv opposite the mark L The horirontal
distances of tlio tnlio and of the mark A from the Aim arc measured
Hv appijmg the gtomclnc principle illustrated in I ig 271 the true occi
pito frontal and bipanetnl diameters of the fcetal skull can now be estimated
REECE'S METHOD
licece concentrates on the measurement of the biparietal thamotcr Ac
(orthng to liLs coiieeptioii the fatal skull (ctclusive of tlie facial hones) is
roughlv egg shajied the long oxw of the ovoid being tlie oecipito frontal
tbametcr and its sliort nxLs ripresenting cither the hipanetal or sulioctiiito
vertical or an intermediate diameter of what he calls the greatest circular
sectif n In anv mdiugram of the fnital ?kull some diameter of this gnatest
circular tcction is hhovvn from the natun of the ceplialie shallow the hi
parietal diameter can lie estimated from the radiogram tor tins purimse we
must know (n) the distance of the newest point of the skull from tlie tube
(IP) , (i) the distance of the Aim from the tube (TF)
In order to amve at tlie distance from the tube of the centre (H) of the
CEPHALOMETRY
403
plane shown in the radiogram 2 inches is added to the measurement TP for
all cases near term (Wliere instead 6f using the approximate estimate of
2inclies greateraccuracvmthefactorPHisdesircd this may be allowed for bj
a consideration of the age of the fatus and the shape of the cephahe shadow
seen on the film Such a refinement however is as a rule not called for )
EmpIoJ^Dg the pnnciple illustrated in Fig 271 the correction factor is
TH TP 4- 2
IP TF
In Ins technique the patient is placed m the supine jxisition on the Potter
Buckj couch the fcetal skull is carefully palpated and the tube centred over
the highest pomt palpated (P) A constant tube film distance (m this case
30 inches) is maintamed
The distance (TP) of the target of the tube from this point is measured by
means of a telescopic measunng rod attached to tlie tube (allowance is made
for the thickness of the abdominal w all) The measurement TP is recorded and
the exposure made
After development the short axis (a diameter of the greatest circular sec
tion) 13 measured on the fihii
15v reference to tables the hipanetal diameter can be readily obtained
McDONOGH S METHOD
In l/cUonojA « luetfiod as in Reece « method the bipanetal measurement
alone IS considered as from the obstetrical aspect it is of major importance
the diameter of tlie greatest circular «ection winch is seen in all projections
itrespcctue of its relation to the film is here regarded as equivalent to the
hipanetal measurement
Tlie techmque is as follows The patient is placed on the Potter Buckj
diaphragm (flat tjq*®) prone position if possible or faihng this supine
rho approximate centre of the ftelal head is located bj palpation and adjusted
over the middle of the Potter Buckj ihapliragm immobili*ation being secured
bj the iiavial band m a position which will not interferG with placing a film m
line with the head
A film js tlien placed alongside the patient on the «ide nearer to the fatal
i cid A graduated lead rule resting aerticalh on the Buckj surface is inter
posed between the patient and film A Lasholm gnd is of assistance but is
not essential
The \ raj tube is positioned on the opposite side of the patient so that its
central ray is projected honzontallv through the mid pomt of the fcetal skull
the ox|>osure made and the film removed
\ second film is placed m the Bucky diaphragm and the tube brought to
the standard height aerticallv above the centre and a second exposure made
Tlie tunc interval between tl e two exposures should be as short as po^ible to
avoid fatal movement
404
OBSTETRICS
TIic liciglit of the fcctal head abo\e the second film be indicated bj the
)ma{,eof the lead rule on the fir<it Selecting from the comideto set of standard
scales, kept in the \ ray dcpirtment, that corresponding to the height
indicated the bipanetal diameter is measured direct from the image on the
second negati\e
Tor routine work a set of standard scales is necessarj, but if the number
of cases is small the measurement mas be obtained bv u«ing tlie follow
mg equation
d
Uhen CD = Greate-jtoircidardiametcrofheadasmeasuretlonthenegative
tf = Distance from X raj tube to film
sf = Height of foBlal skull abo\e film
d ~ Actual greatest circular diameter of fcetal skull
= bipanetal diameter
PpLr\nATTON 01 Standapd — Before makmg a set of standard
hpales one must decide upon the height at uhich the X ra> tube is to be
operated and this setting must bo adhered to in all subsequent measurements
with the particular scales
If the power arndablc will allow a distance of 4 feet or more should be
chosen but with a low powered plant 25 inclies maj bo O'*©!! successfullj ,
though the accuracj diminishes as the distance is decroaved
A rule made from sheet lead about 1 inch wide and reinforced bj wood or
nutal stnps is required One edge is marked bj fine saw cuts at mterrals of
^ inch and the other at iiitcrvais of I cm
This rule IS set abo'e the centre of tho Totter Buck\ diaphragm (flat tjpe)
at a licight of 3 inches and with the tube at the predetermined lieight, radio
graphed on to a Mctiouof 16 x I- inch film, the remainder of w luck is protected
b\ sheet lead Tiic rule is then raised to 3J inches and radiographed on to a fresh
wjction of him This process is continued up to a height of 10 inches Each
sec tion at the time of eaposure is marked b 3 means of lead numbers to indicsfo
the height of the rule
Tlic films on which tho images of the lead rule ha\e been imjinnted are
proce«-<ed in the usual wa\ and after washing each is squeered between two
'jf. '•Jaij: ‘vdlid/uih smi tlltifwvf* drt'j vit/ir stxiys
Iho celluloul IS u^ed as a protection for the gelatine against moisture or
abrasion A smear of Durofix ’ along their climes renders the scales water
prtMjf and allows one to measure direct from wet films without damage
DISPROPORTION
\nlimble irifunnation can be obtained rcgaithng tlio relative size of the
ftctnl licnd and maternal jh'Ivis 1»\ dirert radiograpbv in the prone supine,
CEPHALOMETTRY
405
and lateral vieirs It js important to bear jn mmd that in supine views the
fojtal head is nearer the X-raj tube than is the pelvic bnm , tlie former vrill
therefore be enlarged out of proportion to the Latter In prone positions the
converse liolds Companion of the prone^ and supine radiograms, supple-
mented by a lateral radiogram, will usually give the desired information ns to
the relative size of the foetal head and raatemnl pelvis
Jlore precise information will, of course, be obtained bj corabmed radio
logical pelvimetry and cephalonietrj In comparing the pelvic measiu^menta
vnth the eeplnlometnc ones, however, one must bear in mind that both the
maternal bony pelvis and the foetal bony vault are clothed with soft tissues
{Thoms, bj checking his results before and after dehverj bj Ca?'«nrean section,
finds that 2 mm must be added to the cephalometric measurements as an
allowance for the thickness of tlie scalp )
The leader should be reminded that the radiological demonstration either of
a normallv sized pelvic bnm or of a normally sized fcetal head does not neces-
sarily ensure normal delivery A large liead may give n'se to just as much
difficulty m passing through a normallj sized jiclvis as a normal head wnll cause
in, the case of a contracted peKus
In other words, to assure as great a degree of safety as is possible, both a
normal pelvic bnm ati/i a normal or small foetal skull must be demonstrated
One IS dm en to repeat that while both radiological poh mietrj and cephnlo-
metij have their uses tlio best pelvimeter, in vertex presentations is the
foetal skull Where tlus cannot be applied then the radiologist can give very
valuable information which may save the mothers hfe, by indicating to
the ohstctncinn the necessity or otherwise for Ca?tarean section before
obstetneal interference per vaginam has been allowed to add to the risks
of such a jirocedure
Furthermore one must bear in mind that normal delivery may conceivably
take place even where there is an apparent dtsproportion for the radiologist is
luiahio to assess two unknown factors, viz the strength of tlie ufenne contrac-
tions, ami the degree of skull moulding wlucli will take place during labour
Radiological pelvimetry , if projverly performed, is a procedure of precision,
and the measurcinents <ib not norma ffy aiYer to sny approciaiVo degree as the
result of parturition Cephalometry, on the other hand, lacks this degree of
precision and the ineisnreincnts alter considerably dunng the course of
normal labour
CHAPTER XVXA^
THE RADIOLOGICAL FSTBIAnON OF FQTAI^ MATURITY
luopcil in nifiin cases the chmcal liistorv !<« aiilTicicntl^ relnhle to justify a
rci'-onabh acciirvto estimate of inituritj ofthefatus an element of doubt not
I'll ^6 — rut r t in KU[ ne t on vunuIuiKin of )i}tlR>ep| I ulus I ^ non ml skull
I to to Biitcr or [Hw I on of IimmI ( a* of twui4| tonporol'iii 77 of snnu. { nlicnt in
pron |KMil «m
infreqticnlh an'<*‘i owmp either to uiircrtaint} aljout the date of the Inst
mcnstnml junwl or to conception Imving occurred dtiniig a jicnod of amcnor
406
Pio. 277.— ^anie patient A'? Fig, 270, patient m prone position j nonnnr-suKf
akull (twuii).
The taciiologist, Avhen asked to help in tho asses-sment of the fcctal maturity,
usually bases his estimation on two factors :
(i) Tho size of the fcctus.
(ii) The stage of ossification of tho foetal bones.
Jlost ratliologi.sts of experience will have formed a fairly reliable menial
impression of the size of tlie fcctus at diflerent periods of gestation. In doing so
they irill probably }»ave observed tuo important rules, viz. :
(i) TJ)o maintenance of a standard distance between the X-ray tul . ’
408
OBSTETRICS
the film a convenient distance being 30 inches (Compansons of size cannot
be satisfactonl^ made unlcbs a standard distance is maintained )
(ii) The routine taking of a radiogram aath the patient in the prone position
Tins. IS nece^sarj becnu«e b\ adopting this iwsition, the fcctus is brought
closer to the film and its film image is thus enlarged or distorted as httle
ns possible
TJie differenct m size lietaeen the fcetal skull on a radiogram taken m the
prone jiosilion ami that of the same patient taken m the supine position is at
times most marked (Figs 27C-277)
In estimates of ago from a mere inspection of films ho«e\er, the personal
clement enters too largely into interpretation to allow of the method being of
unucrs,il ntilitj anil a more precise method is obviously desirable
Sucli a method has for some time J>ecn in vogue m the practice of ceplnlo
mctr\ the measurement bj means of \ rajs of one or other of the dinincters of
the fcetal skull Up till recent limes the diameter usuallv measured has been
the ompito frontal If this dinrocter lies parallel to the film it is a matter of
case to measure its exact length from the radiogram either bj the gnd method
of Thoirus or bj the geometric pnnciplc of II allon
Ohs loush in this mcthcKl the foetal head mH«t be orientated w ith precision
for anj appreciable degree of obliquitj of the occipito frontal cbaractcr (except
in the method of Ihovn) wilt render the attempt to estimate this diameter
difilcult or eicn impracticable
^^^cx>^lmg to Seammon and C/iUin« the occipito frontal diameter hoars a
definite relation to the age of the ftetiis TJic following table lias been abstracted
from their <hart
Agr t)l r<rtui< in Cnl'ndat Mentha
t n 1 1 f ihinl riv nth
fourth
rr«h
»ixth
«tvnth
0 cl th
Ort-li IlixlroBUl niamrur
S 8 rm
4 8
%«
B\ examination of a Urge number of fatal skulls at tliffcrtiit stages of
matuntv howe%er ticiimmon and Catlina find that coasidcrablc mdi>idual
sanations niai occur (Fig 278) It is oIimoiis that whilst a certain length of
the occipito frontal diameter max ontheaterajf correspond to a certain pcnoci
ofgc*<tation an estimate of matiintx Irnsed on such measurements maj in aiiv
individual case Jj© an much its three or four weeks out of Tcchnnmg
REECE’S METHOD OF ESTIMATING MATURITY
Tlie biiKinetal diameter of the foetal skull is estimated bj the method
dcscnlxsl on jiage -102
RADIOLOGICAL ESTDIATION OF FCETAL JIATURITT 409
On the assumption that the bipmetal diameter increases by inch
per M eek dunng the last feu iveeks of pregnancy to attain a measurement
of 3 75 mclies at full term, Jieece estimates the number of ueeks from full
term ivhich the fcetus has reached , he claims a considerable degree of
accuracy m his results
ROBERTS METHOD OF ESTIMATION OF MATURITY
If the presentation be a vertex the patient is placed m the prone position
uith a 12 X 10 inch cassette beneath the hj'pogastrjiim, the Potter Bucky
diaphragm not bemg used
She 13 postured so that
the hypogastnum is as
nearly as possible in con
tact until the cassette
The tube is centred
4 feet \ ertically above the
cassette and a radiogram
]$ taken Though not of
the same quality as a
Potter Buckj ladiogram
the fcotal skult is shoum
uith suflloient claritj to
allou of its suboccipito
bregmatic diameter being
measured on the film
Proi ided the skuH is
normal m si/e and the
hj-pogastrium is touching
the cassette the sub
occipito bregmatic diameter m jncbci iiiultiphed b^ ten gnes aiiprovimafely
the mimber of weeks of matuntv Tins apphes onl> to a patient of average
build whose hj'pogastnum has been brought into actual contact with the
fs&setto IS tX'e patient JlipXatfo-jfbexbyTiog^staum cannot be brought into
contact with the cassette or if a lateral view shows the position of the head to
be occipito posterior, n week, or m evlrcme cases two weeks, should lie deducted
from the matuut> computed as aliove
(The method is based on the principle that under the conditions described
a true suboccipito bregmatic diameter of 3 75 inches becomes a film diameter
of 4 inches due allowiuicc being made for the estimated distance from the film,
ill an average case, of this diameter)
It should bo emphasised that Roftcrto’ method of estimating matuntj liere
described is onlj applicable (n) during the last two montlis of pregnancy , and
(i) in vertev presentations, where, in tlie prone |x>sition of the patient, the
UsxliEJa
J«aii
Jlnl-ua
S * 5-6 7 f 9
\(« ol tatusio mIco nr inonUu
J-ir ^78 — a anstion of Offipito frontal riiametcr w ith
age of r«*l»w (From 4S«jn m’»» and CalKtnt )
410
OBSTETRICS
fcDtnl «iku!l IS close to the cissetle In breecli presentations an element
of nncertaintj is introduced bv the vanable height of the fcetal head The
chief merit of this direct or non BncLv method lies m its simphcitj
Limitations of Cephalometric Methods of Estimating Maturity — Ccphalo
metric methoils of estimation of matunts uould be of greater reliability if all
fcctuses %\hen delivered uerc of a standard size but as a full term fcctiis may
Aar\ in ueight from 4 lb to 9 lb it is unreasonable to expect all of them
to base hipanetal diameters of a standaitl size
\\ hilst on the average the radiological estimates of matiintj are found to Iw
faith accurate indmdual cases occur in ivluch the discrepancv on either side
may be as much ns three m ceks Because of thus vanation from the average
which ma\ occur in an\ indi\idual case no cephalometno method of cstimat
mg matunty can lie reganled as unnersalh reliable In any case of
chmeal doubt as to matunty such methods arc how ever justifiable as hemg
the onh alternative means at our disposal But it must lx* realised that they
are not infallible m their results
ESTIMATION OF MATURITY FROM OSSIFIC CENTRES
Apart from tiie general size and ceplmiometnc measurements there
IS another point needing bncf consideration nameh the stage of
Ossification of the bones The radiologist develops a general idea of their
\ ray appeaninccs and degree of calcification from thirteen weeks (when they
arc first demonstrable) to full tenn and bevond tliat to post matunty Tliere
are Iiowcvcr certain ossific centres vvluch make their appearance dunng the
later months of pregnanev which have l)cen reganled as of special importance
The^ are the 09«ifit centres for the lower epiphysis of femur the upper
cpiphv IS of the tibia the os calcis astragalus and cuboid
Tile average dates of appearance of thc<e centres arc as follows
Od c4iJcw ‘'I«t t wcel
V«tnuralu4 -itii lo 3 ‘'r< 1 wrcl
CjiIio i 40tii\>'c«k
L«jwrfr| } 1 of fem ir 3Vth to 40th werk
Ij-prrci phtfdofllia 401htr«-l
Unfortunatelv however these ore roerelv atemge-i and in any individual
nnsn- tfvuniifir'JiJ/t 'ifevtr, Yw '/infMiKt awib Vaa
encounteret! a fiettis of thirtv-seven weeks in whom Iwth the femoral and
tibial epiphvseal centres were very well developed and clearly visihlc on the
radiogram or a ftetus of forty weeks m whom neither was present Ix'iiig coni^
plctely absent on gootl radiograms showing clearly the fcetal knee joint
POST-NIATURITY
Inovsc'. when the patient issitspcctedofluivinggone lievond the computed
-r n ^ radiologist raav l>e called upon to decide whether the
RADIOLOGICAL ESTIMATION OF FCCTAL 3LATURITY 411
fcEtus 13 post-mature or not In post matunty he viill find a large but Tvell-
ossified cranial vault, well defined but not large fontanelles, massive and ^\ell-
o«ssified hrab bones, frequently large and aell developed ossific centres for the
lower end of tlie femur and upper end of the tibia, and well developed ossifio
centres for the os calcis, astragalus, and cuboid
Tlio differential diagnosis between the large and well -ossified head of the
post-mature fostua and the large head of the hydrocephahe fmtus with com-
paratively thm cranial bones and wide fontanelles is referred to later
MEDICO-LECAL ASPECTS
In cases of suspected criminal abortion the radiologist may be called upon
to evaraine the charred remains of the foetus m order to decide whether the
fmtus was viable or not at the time of its destruction It is therefore im-
portant to know what ossific centres are normallj' present in a feetus of twenty -
eight weeks’ gestation, and more particularly those which appear after this
The ossific centres which appear between tbe twentj eighth and fortieth
week are the following (Holtnes and Haggles)
U) Old bone greater comu
Ooecs'x
Lower epiphj eie of femur
Upper epiphpsia of tibia
A£(r«78tu»
Cuboid
Middle phalanx fourth toe
Middle phalanx fUth loe
3'lth to 32nd wceh
3'Cli to 40th n-eeic
3oth to 40th week
40th week
^4(ii to 32ad »eek
4(rth week
29th to Sind week
33rtl to 36t)> week
Radiographic demonstration of air in tbe lungs or stomach of a dead
child IS of value in deadmg whether or not the child hved after birth {Ilajkis)
CHAPTER \XMT
THL FO-TUS rOSmO\ PRESENTATION AND ABNORMALITIES
POSITION AND PRESENTATION
\\ mr RiDiocRVMS in two planer (supine or prone and lateml) the position of
the fcctnsisreadih demonstrated an<lwecansa> whether the occiput or <5aerum
IS to the left or to the right and anterior or postenor
tin ;"0— llrow prr^itatimi pxt«4ion uf I it no luil il furmlt {<f Fi^
41*
Jio 280 — Breoch with Ilexwl
Similarly tlie prosentition — ^vertex, brow, ulioultler, tnin8\erse, breech,
etc — w clearli sJiotni
• rurthennore, ^ nluable information is aroUable as to the degree of flexion or
cxtenBion of the head (Fig 279) the position of the lower hmbs (whether
flexetl or extended in breech ca«ca (Figs 2S0, 2S1 282) a matter of great im-
portance in influencing the succesa of \ersio«) and the pontion of the hands in
relation to the fcctnl head
414
OBSTETRICS
Willi a motile f<ctus ho»c\cr it js soraetimps elisconccrting to note tlie
fiuclden clmnpM in jHHition mIucIi mav occur cien at the £ie%cnth montli or «o
On one ocwision in t lie author scxjKnencc coinjilctc ^cr^.lon of n hrcech jirc«en
tnlion un« upontaneoush performed dunn" the brief intcnal which clapped
during the tuniing o\er of the jnticnt from the supine to the prone pasition At
nn\ etape pnor to the iimklle of the ninth month the radiologist shoulii there
fore l>e cartful to state m Ins report that ‘ at the time of the cTnnnnatjon ’ the
position and pn*sonlation were so and «> '
FffiTUS : POSmOX, PRESENTATIOX, AND ABXOR5IALITIES 416
I'm 2S2. — Full-term roctox Breech with cxternknl Well deNeloiie*! fomoral and tibial
ppij)h>«eiil centres
MULTIPLE PREGNANCY
Ono cannot help being impressed by the frequency u-ith which, in oases of
hydmmnios, t^Tins are demonstrated radiologically wliero no opinion as to
their presence has been formed dinicaUy, and alternatively the frequency vdth
wliich a multiple pregnancy ha.s been proved radiologically to bo absent wlion a
OBSIETRICS
Jjo JS3 — Twin'*- f>rpioinln(, %ertcK nftpiroming brcccli
tetjtatne diagnosis of such Ims Ixvn made climcnll^ In this respect the radio*
graphic CMdenee is usually iKrjond question (Figs 2S3, 284) It should lu
emphasised, liouevcr, tlint the CKiluston of the possibilit 3 of multiple preg*
nancj should l>c made onU after at least tMo satisfactorj radiograms have
IwH’u tnbfn r,wl<oi»cna« rtf expencnce lull he aide to recall cn«cs in
I one railiogmm, but, Iwcau-se of a burst of
FO-TUS POSITION PBESENTATIO^ AND ABNORMALITIES 417
> u S4 — T ns Uothlmici
feet il motiUtj on another PtdioE'rom of the s nne patient no signs of llic fcctus
« ere ^ isiblo T1 ii!> ini^ht quite feasiblj happen to ont of a pur of i\\ ins
Triptets arc occasionally seen (Fig 28o)
When reporting the railuihj,ist should gne detaila as to tie position and
I re cntation < f each fft.tus fchon n with special reftrence to the forecoming
fivtu
\ R u— 2“
FCETUS POSITION PRESENT-VnON AND ABNORAIALITIES 419
EXTRAUTERINE PREGNANCY
If xn tlie radiogram part or nhole of tiio fcDtiis can be seen to be outside
t!je uterine slndow the radiological diagnosis of extrautenne pregnancy can
be made with certamtj
Extrautenne pregnancy luaj sometimes be suspected from an unusually
high or abnormal position of the foitus In such cases hou ever a most careful
collalioration between the radiologi'^t and the obstetncian is of paramount
importance Pneumopentoneal radiography uiH gi\e valuable information
radiography after tlie introduction of a rubier tube into the uterine canty (if
considered justi6able) may lead to error in the presence of abicomiiate uterus
Radiographv after the uitrodoction of hpiodol into the utenne ca\ity may
reveal a normnllv shaped or elongated uterus in ectopic pregnancy tlus
method houeier is not justifiable except in confirmation of the strongest
clinical or radiographic suspicion of extrautenne pregnancy and where a
termination of the pregnancy in anv c^ent is» desirable
FfETAL ANOMALIES AND ABNORMALITIES
On iiiRiiv occasions when hydramnios has been present and when the
obstetncian has been m doubt as to its cause the revelation of a gross fcetal
abnoimahty by radiography has made the diagnosis clear
In the antenatal demonstration of fatal abnorniahties radiology plays a
part of the greatest importance for precis© knowledge of their presence and
presentations may by forewarning the obstetncian not only save him from
considerable embarrassment at dehvery bntmas empower him to concentrate
boldly on measures which aim at the saaang of the mothers hfe regardless of
that of the fcctus
The comtiion abnorimhtics of this ty pc « Inch may lie show n by \ ra\’s are
tbe following
Hydrocephalus — Tbe frankly by drocephabc skull is readily demonstrated
radioiogically (lig 286) The Jaige sire of the fatal skull in relation to its
bod\ and to the iaze of the matenial pelvis usmll\ cstabUshes the diagno^’is
beyond doubt At full term it is sometimes difficult to thfrcrenfiate lietwcen
a mild degree of hydrocephalus and the large skull of post maturity (Tig 287)
In the latter howeier tlie thick and well calcified cranial bones the normally
sized fontnncUcs and the size and adaonced degree of ossification of the limb
hones combined with the clinical Instoiy will usually settle the diagnosis
Occasionally it is a cry difiicult to decide precisely from the radiograms whether
a mild degree of IndroccphaUis is jirescnt or not
The recent w ork of II oWi who nfterdefinitoly estabhshmgadiagnosisofa
by drocephabc a ertex presentation by mdiographv has perforated the enlarged
foetal skull per abdomen so that the head thus reduced in size might pass /
420
OII^TETRICS
tliroiigli tho maternal p-i^sage^t \rit])out difhuilty, is of interest (Figs 28S
2 « 0 )
Anenccphaly — \MnKt a diagnosis of aiiencephaU nn\ often be made on
clinical LMdenee alone cases are oecnsionnlU encountered in tthicli this
h '’ir If tt i rran nl I ren an I wi !>' t •nta/K'H ••
abiiormaliU (ns.ociited with hydromnios) liw Ijctn citincally mistaken for
a Infoch j res?ntation with no mispuion as to nncncephah
1 he n»<liojm»phicnpp(. imnces ehowm^ tlie nbHcneo of the roumh d ennn!
Muilt are charactcnstio (I ig 2J«) 0«-i«ionalh an additional abnommlit\
Midi as spun I itiila h win on tin. ndiogmtn (I it. 201)
rCEiaS POSITION PRESENTATIOX and ABNORSULmES 421
1 (n •»•?? — pom matun fi*< <» No! Ihck crania] tiontx an 1 cell le\-eIopo'J I mb bonM
>c»7J0»»J rrntrrs clonrU v "bJe
In ilemonstrnting this condition rndiogrania should be taken in such
position as will throw the shadow of the foetal skull clear of tht maternal
skeleton The lateral ^ lew is often of value m such cases
Imenccphaly — ^This is ft condition asMiciatetl with an imperfect formation
of the occiput in the region of tlie foramen magnum spma biHda (often of
oonsidcrahle evtent} and retroflexion of the ccr\ical spine {Ballanlynt)
SS — Ilyilroocplialiu I>rfon< tapping bj ponclurt* of skull.
ir 2»0 — KMlroecphalitjafiprtAppini! b> pimctnreofKkulI luasN i{«*[i\pn ensued
4S3
425
"O'— In *n (-(liali lro» | rtwnlutmn »«h vrii innrkr 1 an^lar spinal defonnit> due to
Bpirm I n U
Sjmetimcs the skm nnd clothing tho ekull jn«s directlj from the 1 tck
of the vertex on to tho liack of tho thorax of the fccttis m ithont nnj intert cning
euboccipitai depression
Care must lie taken in reading the radiogram not (o mistake for mien
ceplnU a Pimple hjiwn xteiision of the head and it mu«t also
42b
OBSTETRICS
nmtmlxrcd tint livixn xten m n of lie ccnual hpinc U cnii cd I'
tlijn i<l ttiinuurs
In iniPiircplmK tl c dinpno*‘tit nuhob^ical fcitnre is the demonstration in
ft fmtiis «l osc iicftd IS li\]ten\tcndc<l of an nl norinnlif\ of tlit cenirnl »pmi
or ocnput 292 sfioiis ■»iich a coiHltlion in nJncli this eond inntjoii i"
tlcnrlj kIio^mi
Thyroid Tumour ^\ here this u present in the f etus {Fip 2*13) tl c J ea<l
Is hjpcrextciHlfsl but there is no abnormality of the conical sjiine ns pcen m
FCETUS POSITION, PRESENTATION AND ABNOR'^I4LITIES 429
jniencephalj Tlie antenatal tliagnosia of such a lesion cannot be made by
direct rachographj alone Amniographj in a suspected case maj be helpful
Spina Bifida — In anj radiogram where the normal spinal curve of tlie ffttus
tio .ao — Menmgocpk Ui^i I <«tt«on of fn-im \l normalil% of occtjiital bone notp<i
is Men to bo altered the possibiht> of spina bifida should be considered In
such cases radiograms should be taken in different positions so as to bring the
fatal spine into profile i c to produce a direct lateral \ low of the fcetal spine
In spina bifida there is seen to bo an altcmtioii m the normal spinal cunes.
OBSTETRICS
together wtli a defect in the formation of the ainnons procc'«e‘» tn the affected
area(ljg 204)
Meningocele — ^Though the anc of a meningocele cannot lie ibfferentiated
from the liquor amnu hj direct radiograms, the posMbilit^ of such a Ie«ion
should Ix! borne in mmd m anj ca*® ■where a defect or an abnormal shape of the
skull liones is shown, or where theie is a suspicion of spma bifida Tig 295
xfo JOn — Mi’njm.oirl fptiH after tMivf’Xv (Voine rnx* oj tip i*')
shows a case in whicli nn abnormahta of the occipital Ixino was observed in the
antenatal radiognin togetlier \ntli a high position of tlio fmtus, while a soft
sac could 1)0 palpated per vaginam *Ihe patient went into normal labotirthe
same da\ Tig 20(1 shows the ftetus after delivery
Rudimentary Lltnbs — A satisfactory senes of radiograms should show all
the ftrfal hmbs in detail \m ahnonnahly should be reported
Iig 207 shows a ewe in which nidimcntary fcetal arms were diagnosed
before birth tig 29S shows thw fmtua after dcliven The additional
tlmgno^H of intmutenno deatli in this caso was al-ai made antepartum This
wai made iiossible onU after tw o radiographic examinations at a weck’sintcnal
had Jjeen made and flic fcettis wo* seen to have failed to jncrcn«e in etze m
tlio interval ‘*> 7 ) 011 / 1 ) 1 ^ « (sec later) was onh douhtftilU positive
Tic 20» — ln<rnutpniu* leatl on ? ru I nw»ntarj upi er l€m'h^^{ hagi oswl Lerore letivervj
INTRAUTERINE DEATH
The most reliable sigii of intrauterine fcetal death is that described by
Spalding Mz an o\ernding of the cmmal bones This is due to shrinking of
the brain witli con'seqiient falling in of the vault and nia> be found within
four to scien dftjs of intrauterine death (Figs 299 300 301)
Care must be taken not to confu 2 >e the overriding or moulding of fetal
death with tlmt which norraall^ takes place during engagement of the head or
more markc<lli during labour (hig 302) \cn rarcK o^c^MdlngmaJ be soon
432
OBSTETRICS
^there there is neither intraiitcnnc death nor Mbere the jwtient is m labour ,
j)o^‘«ibl^ such cases maj be associated with scantj liquor ainnu
SpfiMiiij’s sign of o\ emdmg seen at a single radiographic examination can
2 IS . r after <1 livFM Notont I meniarj tipj er lirnlj> centres
for os rat is an I iwtrszaliic well <1<}\ plo/xnl
lliinfore onh Ik rtgarded as strong pretumptue OMdence of iiitmiitenne
tlcntli and must bo cartfull^ eorrelatctl with the clinical evidence
Otlicrndiogniphit signs of mtmitennc death hn\t Ikcd dcscril>cd the^enre
(1) lyjnhjMs of tlie luftihffcacnl f<pfal spnie {/unj/naN) 'Jhw Mgn h of
htlU I line nml often cinnot I* kcs n unless the fo-tnl spine jSKhown exactly in
tin 29*) — Intrs i{eriRe death o*crldppi7»5 of cranial honfw (•S'paWiiyaSJi.n )
prolile an oblirpiitj of position of tlie fcpton ma\ mask, it and it nia\ be pre^nt
in the of liMiig twins
(2) Failing in of the thorax (of \cr> doubtful significance) or raatkeil
kiirhosis of the doiNolttnibar spme
( {} O'tcofiorosis of the fatal bones Tins is more hkelj to bo due to a
fault\ metabolism of the mother or it maj l>c simuKtod h\ the ui.e of too
penetrating a ra\
\ n II — 2S
434
OBSTETRICS
(4) A fcEtus \\liich 13 much too email for the jienocl of amenorrhcen The
fojtnl maturity con l>o estimated bj the method descnbed earlier If tlus be
found to fall short of the chnicnl estimate bj a month or more a suspicion of
fcLtnl death IS mi«od 1 lit it must i f course be rcinemliercd tl at tl e men
stninl 1 js not a!wa\s rehnWe
It must be tmi ha^iscd that an nl scnco c f oierlaj ping of fl e crnninl I ones
doc^ njt neccssonh imjh a hiing fettus In 50 jier cent of the cases of
intrauterine death radiograpiic<l I j the author m> overlapi ing was n»il le at
the first nidiogrnihic exan motion In anj coses (f clinical nr radio! gical
funchi>5 of tlie uterus or nii iiitrcflsc in tlie spinal curre of the feetns ^houii after
an internal is also strong presumptive eiidence of fa?tnl death
It mi! of courho be apiirecnfei? V rnv cvitMieu in anvh eases^ mil
iiccebsanJj be compleinentan to the clinic d endence n close collaboration
between the radiologist and the obstetrician is imperative if mistal es are
to I c av ouled
ClIAirrER XXXVJl
riiACEKTA PRAGMA
Is A cii'C of antep'xrtum hjcmorrlmge ii is of tlie greatest importance to the
chnumn that he should l>e able to a'lecrtaiu whether this bleeding is of
the nature of an ' accidental luemorrlnge " due to a detachment of a nomialK
place<l plicenta or whether it is due to the more senoiis coinphcation of
phc>enta praiia
If the cenix be sufTicientlj dilitcd, either througli labour iiaMtig started
ur thnmgh the IiTraorrhnge ha\nng liocn profuse, the clmtcnn nia}' be able b>
means of the palpating finger to deeule whether the placenta is encroaching on
the Os uten If the cenrix is closed, howc\er, this is not possible and the help
of the ndiolognt nia\ bo ini ded in an effort to decide whether the plaecnta is
nonnallv pheed or whether it i> jiartnllj or wholl) implanted on the lower
uterine Bignient
DIRECT RADIOGRAPHY
.Smoic and Poicell claim that b> a careful inspection of gowl films of the
gra\id uterus thej tan pick out the placenta as a half shadow lietwecn the
houndnrj of the uterus and the fcDtal parts but tlie^ inelndo no cases of
plicenta prroMa m their senes
Attempts hiTC nUo lieen made bj Slairley to diagnose the position of the
jihcenta from an examination of radiograms of the gmsid uterus, m which
there were Humetimes shown groujH of shadowt* which were thought might l>e
iluc to phleboliths or calcified patches in the placenta a radiographic
examination of a numlier of such 00*0 lieforc and aRcr partuntion, together
with the placenta after extrusion I base tontinoed m\«clf tliat such calcifi
cations arc as a rule not m the placenta, but m mesenteric glands which hare
l»ccn disphceil hj the gravid uttnis To base an opmion as to the placental
bite from tlu presence of such calciOeil patches is therefore liable to lead to
error as there is no means bj winch one can be certain whether such ealci
ficatioas arc in the placenta or in the glands
AMNTOCRAPHY
(Uadiographv after injection of opaque fluid into the anmiotie sac)
Jleti^es, JItiUr and /M!ij br the injection of stcunttum iwluie into tJie
amnintic sac m jircgnant women found tliat this substance, mixing with the
PLACENTA PRjE\ LA
437
liquor amnii ami being opiquB to N nvs gate a satisfactory ammogram le a
radiographic shadow representing the ammotio cavitt The fffital parts and the
placenta tterc seen as more transhicent areas in the more opaque Uquor ainmi
Fio 30 — >Io 1 1 RR of k ll I r !!■’ bbour loot to confu ixl with 9/yi / 1 j * a pn of
uitraatctnno deatl )
TJie placenta if dissixisotl ctlge-on to tho incident \ Ta\ beam tlitiefore
hliotted B'a n filling defect on llie edge of nmniotic sac and its site eould
thus be ascertainetl Tliev recordctl no iH-cffccta either to motlior or child
Munro Kerr and ^^ac^■alJ in adopting Ihw methoil found that m some of
their cases the injection of strontium iodide into tJie amniotic vie resulted in the
death of the fatiis Thei therefore substitutotl L»ro eicctnn B for strvntmm
iwlide In a senes of ten cases tlir\ olrfamed good results «ilh no fretal
438
OBSTCTRiaS
fatalities The\ found Iioue\er that even thn non toxie and non irntant
medium tended to tcniimitc pregnnnt\
Technique — ^Tlie injection is made at a site chosen in the louer half of
tlie ahdomtn where it is least hi elj to damage the feetus , i e o\er tiie site
of tiio fatal limbs the maternal «Kin having been prciioiisl^ Kfcnli«ed
and nniestiietised
Bhort the point of the neeilfe is fdt to Imre cnterwl the animottc ca\ntj,
JO ’’O c c of amniotic fluid is withdrawn {tins is not alwnjs essential) and
JO-oOec of Uroselectan C is then injected stow Is an ociasional slight wntli
drawn! of fluid being made at mtcnals during the injection to make sure that
the point of the needle is still free m the amiiiotic ens TJic method slionid
not bt emploscd if there is present a sear of an abdominal incision ns lliere
ma\ then lie a nsk of punctunn^ adherent gut
During the nevt half hour miMiig of the drug with the smniotir fluid 13
enioun|,ed b^ placing the pstieiit m difiereiit positions eser> few minutes A
senes of radiograms is then taken (on 17 x 14 inch fllms) m diflercnt planes—
nntcro posUrior literal and obli(|ue — «o that m one or other of them the
platcntn is ind-on on<{ a corresponding fi^^lng^Icfcct can Iw midt out on
the radiograms The difTcrcntinl diagnosis between accidental hscmorrhige
and plicenta pr-CMi is thus made possible b> the M«uahsation of the
placental filling defect in the upper or the lower part of tlie uterus (higs 303,
SOI)
31id diagnosw is Sometimes rendered diflicidt bv the npjieinm'e of p«oiido
filling defects on the boundary of the utenne shadow due eitiicr to the pres
sure of tmiLsIiieent gas flUed bo«cI or of surroimdmg structures or to the
presence of a lar^e blood clot between the wall of tlic uterus and the hig of
membranes Other less Iikelj sources of error might lie the presence of a
fibroid or the existence of multiple pregnancy
Acrr and Maclay found that ns n result of the injection of Uroselectan B ,
111 our was brought on after an internal \irying from a few hours to five dijs
For this reason the method should l»c restricted to the later weeksof pregnancj
In course of lime no doubt some substance vnll lie discoycred which is
still le>rt irritant than Uro>clectin B and winch will not cause an induction
of hboiir
SnrHf reports rt series af revuntecn cases in whom he perATfiran/ ammvs
graphs with Uro-^eJectan B In twelie cases in trhieh large (17 x 14 inch)
films were iL-«ed the jmsition of the placenta was accurotclj dngno«cd bj
tins mttiiod fn four cases the cxammation was spoilt by the u^e of smaller
(15 X 12 inch) films He therefore stresses the desirnbihtj of using tlie
hrgtr sized film
Ho points out that the diagnosis of the site o! the placenta is difficult onh
if the placenta is implanted m the upper part of the uterus where the shape
of the utenne fundus is mcom>tnnt and where intestinal gi« may prcnlu«
t 303 — \mn oprotn show n>, — -Laieral placenta j ra \ a n case of anlepartutn I »n orrhago
({ ta cnta show mg a« fill wall of item marked b} dotted line) Confimsed bv
nttn ter no ( «lf at on after del er» offotna (Note shallow of LroscJoofan in amn ot e tv
and also stomar) an 1 nlf«t ni*^ of f »t * ) ^
iV*
Fin 301 Vmnincritm wint latent) | Inrmta {ira^in in ft r»s«* of anli-jMirtiiin lia nwrrl nif
<ol Iw|U<>^ H>Hr} I>Ji»r»>ntal fill I B ‘I'-fcrl actn tfthemt •nnr«liiiU' in tlon- l» li iIk> LroseJ'x mi
In tlx' Biiinjolir fftinv nn I tlr rsir iiili'ruv* Cftm^nn tran-'IiKTrc-iw (Vote Lro^eWtan i
fetal *1 fnaeh an 1 tnt«'»lit>e« )
440
PLACENTA PRiElIA
441
pseudo filling defects In his senes the mdiological dngnosis accurate m
all cases of placenta pnivia in\estigated
In the later ueeks of pregnancy he regards the inevitable induction of
labour which results from the injection of XJroselectan B as being relativeh
unimportant he even goes so far as to advise the use of this injection method
Fic — Lot7 placenta la Note vide gap between fcctal s^utl an J funJus of bladder
in suitable cases with the dehbente aim of inducing labour ns being safer
than the usual methods
In thirtv fi\ c cases w here Uro«electan B w is injected there w as one
Hist ince in which death of the foetus occurretl which could not be explained hv
natural causes
If the amount of liquor nmmi is excessive the drug mnj be so diluted that
the shadows obtained are too faint for precise diagnosis if the hquor is scantj
uterine puncture mav be un&ucces.ful
442
OBSTETRICS
RurZc sumnmri«cs tlie indications for ammograjili^ stating that if m a
doubtfulca‘!eofp5ac-entapn?\ia the history of the ease the phj sical signs and
other imjKirtant con'^idemtions — c g age of the patient pint} , desire for a In e
child etc — ire sufficient to indicate tliat Ca^<l^can section is coasidereil as i
po«^iblc mo<le of delneri then aniDK^raphi should be iiorfonncil But if it is
dccidcfl that delnen shall l>e per itai naltirales in anv case then there is little
or nolVnng to be gamed bj subjecting the patient to tho esaminalion Ihe
mam snhie of amniographi appears to be as a deciding factor for or against
deliver! bi Ctesarean section If the diagnosis proves to lie one of central
placenta previa then C.i*sarcari section can be undertaken, with beneficial
results to the child and m full confidence tint the inotlicr is not being cxjiosed
to imneccssarv risk If lateral placenta prrvia is diagnosed natural dchvcrv
lan be avvnilc«\ wnthmil undue apprehension for tbe rafelj of the mother or
the child
PLACENTA PR^\^IA
443
CYSTOGRAPHY
Udc ircim and Urner made a preUmmarv report of a method nhich
they successfuUj diagno&ed the presence of placenta prajvia Tlie method con
sists of an injection into the bhddcr per ureihram of a 12^ per cent solution
of sodium iodide (wluoh is radio-opaque) \ormalIv in the later weeks of
pregnane 3 the anterior portion of the tliui nailed loner utenne segment I cs
I to 307 — Same as F " 306 two weeks later T! o central clot las been «b orbetl or
passed an i the fcrtal sk li and fim ius of bJa Her no v si O v a normal relat On I p
in close apposition to the postero superior margin of the bladder ^epimted
from it onli bj the reflection of the peritoneum If therefore the feeta! head
hes m the lower uterine segment t! e gap separating it from the fundus of the
blad ler in a supine radiogram should be narroa tilulst if there be a placenta
praivia interposed between them the gap should ho widened according to the
degree of interposition (Fig 30^) The met! od therefore presupposes a \ertex
presentation and is not applicable to a breech or a transaerse he Moreoaer
the gap a\ill be greater in the ca^e of a central placenta prajaia than in a
partial placenta preaia depending on the differing thickness of placenta
intera cning
444
OBJblElRiaS
A tlmwback of the method hesm the fact that a central blood clot mil gi\o
the Kimc C} stographic appearnnoes ns n ccntril placenta previa (Figs 306
307) Furthermore the metliotl is only applicible to \ertcx pre.sentations
ill the latter weeks of pregnanej in the earlier stages of pregnancy there
nin\ norinnlh bo a wide gap between the fa.tal he id and the fundus of the
blacUler
The method is of maximum utilitt in the cii**© of central placenta prana
(proxidcd the presence of a central clot can l»c evcUided) In cases of lateral
or marginal phuentn prrxm the nceiirocx of the radiological ilmgnosis b^ this
method is often m doubt
Instead of injecting n radio opaque solution of sodmm lotbdo into the
bladder per ureihram the oral ndministrntion of sodium ortho lodo hippurnfe
(lodorax Alartiiuhle) will gi\e goc*d eistograpliic results but wc Jiaxo no
exjK?rieticc of this method Siimlarl) of course Uroselectan H injected
intraxcnoiHlj can lie used but the injection per ureihram of sodium iodide
commends itself because of its simpluitj and liecnusc of the more ceitam
control of the amount in the bladder
DANCER TO MOTHER OR FCETUS FROM OBSTETRICAL RADIOGRAPHY
Miscoiicojitioii on tills {Kimt lias arisen from a lack of appreciation !)>
ubstetneuns and others of the dincrencc between the dovngc administered m
deep \ raj tbernpt forpohic taremoma menorrhagia etc (wlierc intensive
or prolonged do-'cs of penetrating \ mvs an given with destructive
aims) and the comparativclv small dosage received m diagnostic \ rnv
caaimnatK iis
Ihc intensive do-ige U'<d in «locp \ rav therajiv of the jiolvac organs
has on mcistoii been risjKjiisible lor the c umtiou of fntal developmental
abnoTiwahties (Find/cy /idtfri/ and llogj It can however lie
dcfiiutelv stated that I lit re is no cvidtnrc that dint/imflic antenatal exiKxsurt is
m anv waj harmful to the fafiis «r the mother It is of course advisable to
avoid anv uniiccts-ar^ rcjietition of radiogripbic. cxammatiuna four or live
dininiostii exposures however mav I e made at one fcssioii and repealed at
intervals of one month if nee-cssnrv without anv risk of damage eitlier to
moii'icr or i7i.rus
OoUUlrtii find Jlurphy alter an exhaustive review of the hteraturo on tho
Hiihjict conclude that then is no evultnce that diagnostic pelvic raebation
ehinng pripmncv is dcletcnons in anv wav to the health of the suViscquent
offspring
riicrajxjutic X nv>s should not be given to tho pclv ts if pregnanej w known
to have occurred anti if prcgnantj occurs diinng the course of such treatment,
the pregnanej should at once lie lerminafcd
PLACENTA PREVIA
445
BrBLIOGRAPHV
Aujavo, G , Zentrall Gynal . 1928, LIl (2) 2084
Albert, Sfrhn JiJin frc?infehr , 1809, XXXTI, 33»
Bailet, n , and Bagg, H J , J Obttet , 1923, V, 46!
Baixanttve, J \r, ” Antenatal Patholojry and Hygiene The Embrvo ” EdinbtirHi,
1004
Bupke, F J,J Obstet Oijn (Brit E»ij» ). 1935, XLII, 1096
CnASSARD and Lapine, J Ifadtof el dEltdral . 1923. VIl. 113
CouRTVET Gage, H , m “ Recent Advances in Obstetrics and G\mcoln£;v (Bourne
A Wdhams) London, 1932
Fivdlat, P , j a M a , 1930, XCV, 857
Goldsteps, L , and lIimniT, D P, Inter J /r<»ewf . 1929, XXII, 322
IIaJKis, If, iniicef, 1934, 11, 114
Uecseb, C , Zancet, 192S, 11, 1111
Holmes, G W , and Rcggles. H E . ‘ Roentgen Interpretation London, 1026
IIooTov, 1V H . Brii J KaAid ,1932 4 . 617
Jarctio, j , “ GvnTcolQgical Roentgenology. InnaL o/ Boent , XIII, 38S
JesoMAN, 11 , Zentralb Gynal , 192S, LH, 2788
Kerp, j M M , and SIackat, W G , Tmne ZTdiw Ob»t Soe , 1933. LIIl 21
McDonogji, C Xj,Brit J J?a<boI. 1931 ITII, 613
llATTnEns. ll B , Amfr J Obstet , 1930. XX, 612
■\Ie>Ee«, T 0 , JllLLER, J P , and Hout, L E Jincr J Boent , lOlO, XXIV. 361
IIURPIIT, D P , *I»ner j Obdel , 1930, XX. "24
PETERaOV. R , Burg Ggn Obftel , 192|, XXX, 154
Reece, L N.Proc Boy Soo lied, 1935 XXVHl, 489
Roberts, R E , JJnt J 1927, XXXII, 11 , Ibid , 1035, VllI COl , Five Bog
Soe 2Ied , 1934, XXVlI. 12U
Rowden.L a, Brit J Radiol . 1931, IV, 432. /6id . 1035, VIII, CIO
SCAUMOS, R E , and Calktss, L a. Development and gro\vtb of tbe linmaii bod^ ui
tbe fetal period *’ Umv Minnesota Pre'«. 1929
SAOtv, IV, and Powell, C B , Amer J Boent , 1934, XXXI. 37
SPAlorvo, A B , Surff Ggn Otstel . 1922, XXXIV. 754
Thoms, H , Amer J Obstet . 1922 IV. 257 , JAMA, 1930, XCV, 2!
UnE., W H , Wecm, T W , and UP^EB, J A , Jnier J Boenl , 1934, XXXI, 230
Walsh. C II , ZfnJ ZIed J . 1931, 1. 1035
IVaLTOV, n J , Surg Ggn ObsM , 1031, LIU, 530, Amer J Boertf , 1B31, XS.Y, 758
INDEX
A
Abdominal Tvall, pentoneal gas inflation
through, diagnostic applications, 3fi9
technique of, 367
Abscess, appendix. loeali^H, 221
liver, calcified, ibagnosis from gall atones, 327
radiological appearances of, 3-1^
penrenal, e\cntnitiQn of diaphragm in, 19-1
Kubhepatic, eventration of diaphragm in, 104
Bubphrcnic. ewntration of diaphragm m, 193
radiological appearances of, 103
Achalasia of cardia, 28
of pvlorus, effect on gastric evacuation, 56
with gastric ulcer. 69. 70
Achj bn gastrica, simple, gastric mucosa in, 81
Actinonucoais of colon, 266
of stomach 84
Addison’s an’cmia, atrophic gastntis of, 81
di9oa»e. radiological demoastration of, 338
Ailhesions, gostne. 77
pengOitne, contraction of, cauiing cascade
atoiBacb, 48
Ailreno genital sradrome, perirenal inflation
m demoastration of, 338
Acrophag} . pathological, 1 12
Airtn«ulHst<on of stomach, 43
Akerlund deformity and retraction m duodenal
ulcer, 13 (
Alimentary canal, examination of, banum
emuleioD foe, 34
general toclinique, 34
foreign borlies in, opaque, IdC
transparent, 107
ilmmoprnphj , 436
dangers of, 438
indications for, 440
technique of. 438
Amniolicsae, injection of opaque fluid into, 436
Ampulla of S'ater, dilatation of, 142
normal, radiological appearance of, 123
Anaemia, AUdi«on«, atrophic gasfntis of, 81
Anenccjihah of feetua, radiological demonstra
tionof, 420
Antiperi'talsis of colon, 239
Antomicei s technique of choices stographv, 317
Aperients precciling banum meal examination,
37
Appendicitin, chronic, pathology of, 216
radjojogjcal signs of, adhcsioas, 218
appendicular stasis, 220
eoncreiiojis, 217
fixation of appendix, 218
fixation of cienjnj and ileum. 218
gastric stasis, 221
ileaJ stasis, J»^0
irrcgu!ant\ oflumtn. 217
non or ineomplete fiJlmg, 217 ,
tenderness on pressure, 220 !
Appendix, abscess of, localised, 221
diagnosis from ifco caxja? tuberculosis,
263
cancer of, 221
diverticuia of, 222
normal, radiological appearances of, 213, 215
^ling and emptving of, 214
radiologv of, technique of, 213
Arteno mc^nlene oceJusjon, chrome, causing
duodenal ileus, 143
Ascans Jumbricoides m ileum, radiological
demonstration of, 107
B
Rariiun air double contrast enema m exatntna
tion of colon, 228
bl'iCUlt, ID
cieam followe*! bv water jn diagnosis of
cesophsceal foreign boibes, 21
use of, ID
use of. m diagnosis of orsophagcal foreign
boilit H, 21
emulsion, <ie«iderafo of, 34
in duodenal cxazQination, 116
preparation of, 35
eiionia appearances in carcinoma of colon,
279
in chronic ohstnietion of colon 209
in divertiruhtis ofcolon 287
in gastric fixtulT-, 8*
m imtabln colon, 2S3
in mucous colitis, 236
forroulio of, 33
■n examination of colon. 223
apparatus and administration, 22 >
opaque medium, 224
preparation of, 224
of pancreas, 352
meal, appearances in givvinc h.,tulJ*, 8 > _
examination, double meal technique, 37
of chronic intcstinol obstruction, pre-
cautions m are of, 205
oftbronio obstruction of colon, 270
of colon, 223
of diverticulitis of colon, 2S7
of mucoU4 colitis, 256
of pancreas, 331
of peptic ulcer, 57
preliminarj preparation, apmentB, 3i
fo^, 3
technique o
time inters I
formula of, 33
pellet, 10
xrool, 10
447
448
INDEX
DaniJin » ool, use of, m tUa^nosia of co-^liaswal
foPPum bothfi. 21
lltrs’ii erplorfltor. a«o of, 42
jirotnutf lont , use of, m radwlogiea) c'camiiut
tion rollout in? xtomach operution, 152
Heioar, pcrxmimon, m ttomaeh. 10“
Ilile duct«. mairormatioiis of, eongemtal. 320
tumours of. 341
lldmr\ tmrt, anntnni) ami }>}i^i>iolog\ of, 30 >
(Kslvinc^iaof 336
extrolM'pnlK', anntom^ of, 303
mnIformAltons of, congenital 320
pnlliology of 320
radiological txamination of prelimuian
pn-paration, 314
tcf Unique of. 114
vmialbtaiion nf postoperative 341
ISillrotlk I njirmtion railioloftiral appearances
after. 1 ^0
Ilillrolli H n;>eraiion, eomplications of, 172
m'liolosrieal nppearaneea after 171
Borborjpmi. 1 13
C
CaYuro, anatomy of, 236
carcinomA of, dinsno^n from tiibereulosM
2 fl 1
filling of. 237
haiutml chuming m 231
rmlvftlogwal appearances of, it\ svMetnivtcnu
-’47
stoeis of, 20?
umlmeemlnl oatiK« of 2(4
CnlculiiM, nppemlis, 317
jmll llailtler 321
intnihepfltir. diagnoau from KAlt-eloiie^ 327
kilnev. duisminis from gall Stones 3 >6
pnncmitK*. 3Vi
diagnoKH from gall stonm 3.’4
wtlivarv 2
differenlinl diagnosis of S
riulioLrapliy of 4
f aneer A« unJrr rtanK* cf nrynttm and rrjmna
Cardid, achalasia of, 2S
Canliiximetn a’tiolog) and patholntiy of, 2!4
radio! jgiral appeonincea of 2S
Irrniment of, radicgrai hic lontrol of, 29
Cartilage*, coiital calcill'sl. iliaglio«H fnw* gall
■tone*. 327
f’ophaloineir). diA]iroportinn Mi 401
McDonogh’s meiboil, 403
preparation of standani Mcah's 40i
Jleere a metho*!, 402
Rowden’* nvctlaoil, 402
Thoms* inelhoil, <01
Walton's method, 402
Chaou! cotnprp«i«lon band, use of, 42
in radiological examuiAlion, folSootog
gustne operations, 152
fluueard and L^ninea method of peUKoetrj,
3W
Choice^ itertomv , pendiioalmitn foltovrins, 137
Cholecy'stitLs, acute, radiological appearances
of, 322
thronie, mild, radiologieal appearance* of.
323
• intensity of sliadovr, 324
rato of einptv mg of coll bladder,
324
rate of filling of gall bladder, 323
radiological appeamnees of, 322
obliterans. 322
(liolec)"to duodenal fistula, 137
Choicer sto-ilmxiciionioniv radiological appear*
ancea after, IS'i
Cliolcrv-lo gastne fistula 6>
fholeev-to-gastrostoniv, radiolc^cHl appear
onees after, 153
Choloevstograpliv. IIS
findings m eficet of extrabiliarv iImilso on,
343
in atute liver neenMis, (ontniinili<.ated, 342
in studv of bile coneentration, 312
intravenous, rontmmdieation*, 315
technique of, 316
oral, inUnsive, technique of. 319
single do-o. toehnique of. 318
rapid, technique of 317
Choice) stostomv gall Llaildcr after, 343
Cl>nle*tem»is 323
Ctrliac disease mdiological appearance* in
adtili*. 2-11
in infants. 270
CoUtva due to »]veeifie infections, 361
mucous, radiological appearances of, S50
simple 275
svpiulitir. 262
ut^rative rtiolngv of, 2*6
pathologv of, 217
radudogjcal appeorance* developed stage
26(1
hv'peq lastic and sclerotic elage. 20]
stage of oiucl 260
Odon. absent e of, 2o2
•elinomvcosu of. 266
luhno-careinoma of 278
ailctioma of multiple, 277
adhesiomt of radiological apjiearancoi of 252
after inflation with gas, mdtologieal appear
ance* of 234
anatomical vanationn of 341
■natomv of. 216
anomaliea of, due to lulhesion* and hernia*.
252
fixation 240
length, 241
rotation. 243
tnmor, 244
wzc, 24S
anti]'emtah>w of 239
«*ecn<ling anatom) of, 236
carciiKima of rnr<-phaloiil, 28l. 2S2
cnterosi>a.sm in 2A4
fixation of grow th 284 ^
luorbiil analornv and site of, 278
riwJiological a[ peoranres of 278
INDEX
449
Colon.carcinomaof, ratlioIogiealapjiearnncMof,
filling defect, chfferentialdiagnosLs of,
varieties of, 278
obstructive signs, 283
scirrhous, 278
ilc-scendrng anil ifiac portions, anatomv of,
238
dilatation of, congenital, jotiologr and moe
bid anatomy of, 248
clinical features of, 248
racliologicst appearances of, 248
after sv inpathectomv , 249
displacement of, subphrenic, 241
diverticula of, J/iflammatorv changes in,
28C
pathofogv of 2S5
perforation of, 293
site of, 286
diverticulitis of. ictJolc^ of, 2Sj
clinical fcaturesi of, 285
complications of, 287
definition and temunologv of, 285
radiological appearances of, after barmm
meal, 2*13
after thorium three stage enema, 294
pro divertirular stage, 288
stage of diverticulitis, 290
stage of diverticulo»is, 289
technique. 287
treatment of, radiological control of 295
diverttoulosta of 28s
double barrclletl, 2^2
enuamation of barium aic double eontrast
enema 228
barium enema, 223
banum meal. 223
plain radiogram 223
thannm air double contrast enema. 229
filled, radiological appearances of, 232
fixation of. bv adhesions, 273
function of, 237
antiperwtaUi-s 239
hlluiK, 23T
mass movement 238
pendulum movement of Kiovler, 239
gaseous distension of, lausing gastric dis
placement, 110
iiaustrai churning of 239
herniation of, 234
inflaminatorj diseases of. 2o4
uisulllationof. in thorium air double contrast
examination, 231
irritable, radiological af'pearancos of, 255
long, 241
nmoosal pattern of, pathological variations
in. 233
mii'w uliir coat of, 237
ob-.truction of, 267, 2ti't
ecut», 269
chronic, 269
pelvic, anntomv of, 236
jventoneal atUiesions mvolung, 252
plication of, types and form of, 232
\.R .n~29
Galon, poIypovH of, 27"
radiOlogicat appearances of. in v isccrontosis.
247
rate of tnm«it through, 23'*
aarcoma of, 284
afiort, 241
oigmoid volv ultts of, 274
splenic flexure. «nntom> of, 236
sta>ia of, 267
transverse, anatomv of. 230
tumours of, benign. 277
malignant 278
ulcer of, enrcmomntouH perforation of, 284
upper, filling of. 237
Colosposm. radiological appearances of, 2>3
Compression in diagnosis of duodenal ulcer, 126
Constipation, 267
cohe, 267
radiological flppearaiicps of. 268
rectal radiological appearances of, 268
Oane a string «ign 239. 230
Crohn s di'^ase clinical features of, 210
diflerentinl diagnosis of. 212
radiologirol appearances of, 211
Cv&tographv in diagnojus of placenta pr-evia,
443
Cvats ofliver livriafid. 349
ralcified iliagnot.i> from gall stones. 327
ofovarv. 363
demonvtrniion of 371*
of pancreas, 374
of spleen bvdatid 371
of stomach 86
D
Deglutition, process of, 10
Diaphragm, anatomy of 179
contour of. irregularities of 1^0
elevation of unilateral congemtal. 100
eienlration of, 190
»*tioIoRv of, 100
ildferential tliagnosis of, 192
patholog> of, 191
radiological appearances of, canlmo <lis-
placement, 192
contents of dome, 191
diaphragmatic outline, 191
gastTicfOTrtents, 192
pastne deformitv , 102
lung lissTie V isible through dome, 191
movements of dome, 191
Jitmia of, 180 .Sre al^ Ilemm, dia-
phragmatic
mfenor relationship-. 179
movements of. ISO
normal, mdjologicnl appianinies, 179
upwanl displscement of one dome of. causes
of. 180
Dnerticulo. gaslnc. 1)77
pliaryruteal. 1 7
Diverticulitis of colon, 285 Arc Colon*
divert iridiln
Diverticulosi-. ilnoileiinl, 138
450
INDEX
Duoiknat wkI pa“lti<' iilrer m<‘i<Ii'nop of 57
Cnbo 1/1 fitu, ra/liulopiral ap{>car(ince of, 107
Duoilraitis, 133
nidiologiral nf'pfHininfiw of liefuron bulb
anri ainpuIU, 13(1
in bulb, 14 I
I)iioflcno jfjiiniil floxurp, normal, railiolopical
ni)Ij<>aranoo of 1J1
Dufxfaio jcjuno*lom\, ruiliolo^ioal np|>tar
nnroH nflpr, 1*4
DuoilvTium abnotmnlitips of ronRonital 147
adenoniR of. 14'l
afur oporalmn, railiolopiral evaimnation
tocMKiue of, I3l
oiiatomicBl nIation>> of 114
aniitoin> of 114
bulb of nKlioIopioal oi'iH'iiranct* of IIO
lanatran'i In diip (o <ln;no of iilhne.
US
ihip 10 habilin of patiHit. tlH
lino to poiituro of pattmt, IIO
camiioinn of patliolopr of 1 SO
miliolopiial nppporanrrs of ISO
liiirrtKula of ampuHari, I4>
railioloirirnl appinrvKp of 144
cUiisific otion nnU iniidciKO of. n**
prunar>,<.!uira< tcri-jtii'N of ISS
liilTorcntui) diatrno'ia of 140
pnilioloe? of 130
•'■ouclo of 137
ratlioioL’icftl apponranroi of 130
wvuniliirs, piilxioii ti[>c 141
raJioI ifnral app/arancox of. 141
•'>'tnptOfn«toloffi of 144
tmction tipc 141
■vmptotnxof ]J‘|
fibroma of 149
fiatulu of rt(< mal 137
uitimal 137
i>i<>rilary(<tiKrit« of lii-ail of panrniw 130
Hiiii'xiii^rpiion of I4U
inipnum tltisl 14H
niobilo i4S
lipoma of, 149
looprd. HI. 14S
niNomaor, 14>i
normal. Jl4
radioliariral a(iiK-anin(-< <.f ninixilla of
Satrr 147
<lu‘«lfno j»junal 11' Tiiro 143
fir»< j>/irtiun. iliioilonal bulb 116
porlioii ilntal to bulb 140
railiolosfit-al apfirxiraiiri^ ,,f u,
pto-,x 247
ra>iirib>cit-nl cxaiumatioii nf trv-)iniriiH> of
115 '
opa'i’to inodium no
planoin US_
pTTWim in 117
in sitiM (urliali. rommuiir* inrMpn
txmim. 14(1
Duodennm, lumourx of, bpnipi. U9
tlloprof, rimioni fonturoH of, 144
(oral branrh ilifonniti, 129
foltouincjraA'trujejunoxlomi, 164
(;aii(nc sto-ux following, 13)
{Mtibnition of, 144
• jK-rxisfonf ni-ck '■•(ignm,124
pino-troc (leformui , 149
radiological appearance of. Hi.eexNorj'
pocket. 134
ftdjaecnt ehani::e>i in bulb, 127
Akerlund deformitj-, 131
deforwiitj from penetraimfr niter, 134
dcformit} of bulb noxorialed irilb dui
tortion of pvloric canal 131
Ccneral bulb dcfonmti , 12‘>
liealing atace, 134
•ncixura deformiti. J3I
nicbo deformity, 131
retraction (Akerlund), 131
seeondan dwturbnncM of slomnch in,
134
amall atonoaetl bulb 134
vwualjxed ulcer crater, 144
ehanirocl. ileformiti, 149
aite of, 124
D>sche»in, 26S
DvakeziA. 26S
Ujukineaia. biliarj, 336
Di<3iliagia. 14
p)inr>nsenl. IS
K
Fntero|>»CKn 240
Kntero^'aem in carcinoma of colon. 464
Kpisiottia, rOle of, in deglutition, 11
Fxtotnac en coupe 6 champagne. 4S
Fttraulerme tumours, demoibtration of, 37S
F
Fallopian lubcx, injection of ojuique fluid mio,
370
patency of, iniT“tiitatifm of, 364
(ranMUtennainfUlion of. (onlruinibcationii,
360
texlmirpie of, SCO
FmnejV pjloroploati, r»iboli«nal appear,
anccxi after, 170
Fwtula.cliolecielcxolonn , 339
choIrctatoxIuodenBl. 137
eholoc'Bto pastnc, B'l
duodenal. 137
gaatnr, 84
radtological apjiearancex of, 84, hS
giMtro-eoljc, 84
ftillovTing gaxtro jejunoxlctmi ,84, 167
deal. 203*
jojunal. 203
«abi arj , 0
Firtnla in ano. 490
Florrulation in < xammatioii of colon, 2-4
INDEX
451
Fluoro‘«copj of appendix. 214 _
of diaphragmatichemia, 181
ofduMenum. 11)
of resophagiH in cardiospasm, 20
of small mtestine, 197
of stomach, 39
use of, in treatment of fcsophageal slnctura
L\ bougies, 27
Feetus, nnotnaliea and abnormalities of, 419
anencepbah , 420
hvdrorephnlus, 419
iniencephnlv, 421
memngoccete, 430
rudimentnrj limbs, 430
spina bifitla 429
thyroid tumour, 428
danger to, from deep X raN therapj,444
immobilisation of in obstetric radiologj, SSI
intrauterine death of ratliological dcroonstra
tion of 431
matuntN of, radiological estimation ot. 40(5
factors in, 407
from oasifie centres, 410
Lmitation of cephalometric locthcls
410
medico legal aspects of. 411
Reece a method, 408
Roberts method, 409
oecipito frontal diameter of. in relation to
maturitv. 408
position and presentation of. radiological
appearances of. 412
post niaturitt of 410
Foreign bodies in fthmentnr\ <anal, iw
in cpsophagus opaque. 19
tranapamit, 20
Fraenkel « pen^taltic jump sign m cancer of
stomach 90
sign in gastric ulcer, 71
Gage Courtnes mcthotl of pel\ imotr\. 398
Gall bladder adenoma of, 340
adhesions of, 318
anatomj of JOj
« nn.inomaof primart 341
ihstension of, radiological apiicaranccs of
336
double, 120
cmpt\ ing of. mechanism of, 31 -
radiological appearances of. plia>o oi
contraction. 111
preparator\ phase, 313
re»tinc phase, 311
function of, 311
long or hvposthenic, rn Iiological aj»peor
ancesohSll
malformations of. congenital. 3.0
non-calcifie*!. Msibdits of, without cliolo
ejstograplis. 334
nonnal, parts of, 39 >
t jpes of, 301
Gallbladder, ovoul or sthenic, radiological
appcarancea of, in erect position, 307
m prone position, 306
in RUpme position, 307
papilloma of, 340
{Mircelatn, 33!
radiological appearances of, after chole-
cystectomy, 343
splieroidal or hypersthenic, radiological
appearances of, 308
Rtrawberrv, 123
tumours of, radiological appearances of, 340
walls of, calcification of, 331
Gall stones, 323
cliolecystograpliy and, 328
composition of, 325
differential diagnosis of, 326
imiiaction of, in intestine, 276
Gas bubble sign in cant er of gastric fundas, 97
Gastrectomy, complete, Moynihan, radio
logical appearances after, early and
late, 177. 178
partial, Billroth. II, eomphcations of, 172
radiological appearances after, 171
Polya, 172
Polya Balfour, 173
Fob a Iinsterer, 176
Polya Lake, 178
Polva Moymiliaii, 172
eomphcations of, 174
radiological appearanics after, 173
Gastric adhesions, 77
and iluodenal ulcer, incidence of, 67
contents in radiological examination of
e\-entration of diaphragm, 102
etacuation, rate of, factors goteming pen
staUis. 60
py lorio function. S6
toDus of stomach, 50
typo of meal, 65
inuco-sA. changes in, due to distension with
banum emulsion, 54
due to extraneous factors, 54
due to extrinsic procure, 51
due to inflammation, 51
due to neoplasms, 53
due to presence of food, 54
due to iiker, 51
pathological, 54
plijuiological, 14
normal, 52
form and functions of, o2
rugs? in gastritis, 60
incrcasoU thickness of. in duodenal nicer
112
normal, 52
stasis following duodenal ulcer, 133
ulcer, acute, pathology of. S8
eamnoniutoas OS
cliTonic, active ritdioli^ieal appioruncea
in bsniim fillei] stomach, 60-61
liealmg, radiological appearances in
banum filled stomach, 04
pathology of, 58
X.B. II — 20*^
452
IKDUX
"Sa^tric ulcer, clironip, mte of, 58
tiire Mill fonu of, IS
follwuHv: {'astrojejMno«tom%, 1R2
I xnli'ici ten'1 meiM on p«“wure TO
iiuili.nsnt and simple, riuliolot*ica1 dilTer
ential diai^noxii* of, 100
patholojr^ of, 5S
nuliolofficat appeftrnnrea of cieatncM)
surn-i.liour friaxs contracture ofntomaeh,
75
pjlonc steocww 71
prater in mucool pattern raliojrram
'>0
direct siffti 70
in luinuin fiileel stomach, flO
indirect Slims ^raenktls peristaltic
pimp 71
La^tric evaluation, TO
pastrospasm 66
pinstaUis 70
M-pmcntal ripulitj anil straiplit
now of jeeser curve, 71
xixe anil tone of stomach, 6*1
HimpU and mahimnjit wuliolopicat <U(r*.r
entuti diapnrwH of 100
inatiotott> ofiancer 8S
simplex, C'l
aiilMiciite pntholofrv of oS
mill nonnal pjlonc function 61
mtli pvlone flchalaam 60 70
mill p>l iric olwtruofion ro 70
mtli jiiloroepasin CO 70
Gattniix hij
alratdiK hi
followinR padrn ji juiioNtoinv lUl
ivcruinaaiomotii Hi
Oastro colic fietiiU 84
fiB<tropftsln>»lonij radiolopual n{ { enroncoa
after 151
Oa^lro licnl rctlex 200
Oaatro jejunal ulcer folinrinp pahlrojejun
iHloruv lot
OaMm joj'uio-<oltc tisiula 84
Ga<tro jejuiiuntoTiii antinor rn lKrlot.i<al
«p]xnninct>, after 17(1
rnmplicatinni cif diiodeiinl ileus |4li
|KHt<nor rompluntion* if iiniraMiin of
pjinn nnlniin 1(17
•liirnpiiu; stoiua Mil
irasiritH lOI
jejunal diimf 111 . tOI
jejunifw ICI
rnaJfxvitio/j of iriniia JB-J
luilrrmini; of clotna 167
jicjilic ulc« r 102
radioloin at appenran'-eH of IbO-lOJ
rclroifradc jcjiino pastne intuoiuipii
tion, 169
railiolncnal appearftnerM after pressure
control of clierenV loop m, 159
rajiolostual apnearance* after 157
GafltrtHfMwm In lirect sum of ^ivtn- ul'cr, 00
intrinsic or e»tna*i'', (IS
Gc a d.-s.*e, 2V)
Genital tract, female, ra<lioirrapli\ of, 161
Glands ralciflcd, m abilomen, dinitnoci.-i from
(call sUiiies, 327
Gtenard a discasi , 346
CjTupcoIotrv rodiolott} tn 163
II
Ifaaiick. niche of S9
Heart dieulacement of m eventration of
<lui(thr8{;m ID2
Hepato diaphrsinnalic mtcrpoMtion of colon,
341
llcpalo liennfrrnpht 347
Henna diaphraiTTnatic acquireil ISl
non traumatic 184
ndiotoeical appearances uf IK 1
traumata 187
mlioluitical appiaronies of, 189
Anatomical features of 181
clAMifleation of 181
coni^mital, 181
para ipsojilifln'Col, 181
raiitoloKicai Bpiwaraivecs of 186
through tlio dome 18’
radiotoeiial opiKxirsnces of 180
through the foramen of itoriraKni 184
throiizh tire pleuro peritoneal liiatiu
181
cmhnolotry of JSO
ca<liolo-,.icalcxaimnation toclmiqui, of 185
of >10011 intestine 207
ll< rters iliMAsc 2>0
llirM-lispninzsdis(iiw 248
Hooton A tiM tiiod of (‘eliimetn , 19S
IlnrltckM elutdou fopil u«‘ of, in ahrocidarv
tract examination 3*>
llounon. valves of 297
livdrocephftlus of frrtiis rerliolaziral demon
Atralion of, 410
llvdrosalpinx inrlicntiona of 376
lljpcf]Hri>tal>ts in duoilenal uleir 132
of stomach 4 6
llvpcrtoniis in duodenal ulcer 132
nf elvmarh 46
ll>popharjti(.unl eamn' mu 17
Ileitis chrunir 201
I lastic elitucnl feulurcs of 210
differentud diii{'n'>os of 212
rudioloiwo} appearnnees of 211
n*Biunal 210
toherculous htpertrojiuc 210
III ernlire 2(fl
Ileo-cipcal tutsTculoH t hnieal fi iitiifcs of. 263
differential diuinio'is of 26>
I nlholnfrj of 263
rsdiotauual appearance* of 261
valve 201
Ileo reflex 200 221
Ileum anatomv of, lt>7
carcinoma of, 20S
INDEX
453
Iltum, fistula of, 203
Rail stone impaction in, 270
terminal radidogjonl eppearanopg of «00
Ileus duodenal chronic, 1-13
in children, 147
non obstructive, 143
obstruct n c, due to adhesions and bands, ?48
due to arteno mesentene occlusion,
radiological appearances Of, 145
B^TnptomntoIogv of, 144 ’
due to evtrmsio pressure, I43
turnniu;. 146
due to gnstro jejunostomy, 145
duo to intrinsic ksiona, 143
due to perwluodenitis, 146
Incisiira, posterior (pancreatic), nf Twinin"
39, f»0 352
Inienccphah of ftetus, radiological demousira
tion of. 421
Intestine, large, anatomj of, 236
function of, 237
rate of transit through 239
Bmall anatom> of, 197
carcinoma of 208
diseavca of. 202
diierticulA of, ftcquiretl, 202
fUtute of 203
herniic of, 207
Meckel a diverticulum of, 202
RioramenCa of, radiological appearances of
108
obstruction of, acute 204
chroiuc, 205
radiological appearances of, in erect
position, 200
in supine or prouc Position, 20G
radiological appearances of, m vaseero
ptosLS, 247
radiological examination of, tOcbnique of.
197
rate of tran<it through, 200
sarcoma of 209
tubereuloMs of 20J
tumours of innocent 208
inaiignont, 208
Intussusception, 271
classiScation of, 272
yUjuwvt'guL'O.nti; jsy.'sg’.a'il/', .tiiUn»;y7^ gcastnc*
;e;unostoiD>, 169
pathologiial anatcimj of, 272
radiological appearances of, 273
J
Jejunal dumping following gasl to jajtuiostomv,
161
ulcer foHoinng gastro jcjiujoitoniv, J64
Jejiimtw following Rostro jejunostopij, 161
Jejunum, anatomv of, 107
tistula of, 203
tnotemenfs of, radiological appearances of,
19S
K
Kidnej'S, enlargement of, causing gaatno dcs
placement, 108
Kienbock’a Riga, 191
Koehers operation, radiological appearances
after, 1S6
t
LarvTigeal orifice, closure of, in deglutition 11
Lannx, rfiloof, m deglutition, 10
Limbs, rudimentan, of ftEtiis, radiological
demonstration of, 430
Limtis plastica, caremomatous, 92
Lipiorfof use of. m sialogropbv , 3
Liver, abscess of, radiological ap[>earances of,
349
anatomical features of, 347
calcification of, radiological appearances of,
349
evatsof, hv dated radiological appearances of,
349
disooaesof, 341
enlargement of causing gastric displace
ment, lOS
eventration of diaphragm in 194
general causes of. J47
radiological appearances of, 317
metastascs of, demonstration bj thorotrast,
348, 349
necrosis of. acute cholecystography contra
indicated 342
rmtioli^ical appearances of, after thorotrast
administration, 348
in visceroptosis, 247
esammation of. hepato lienogreph^, 347
tumours of, elevation of diaphragm m, 191
M
McDoni^h’s method of cephalometry, 403 '
MageDst-a3.se, 52
Meal, tvpe of, effect on gastric evacuation, 53
Mecl».el«divertrcutum, varicficK of, 202
Megabulbus 147
Megacolon 248
Megaduodenum, 143
Mcningoctete in foetus, radiological demoastra*
tion of, 430
Memicus tfleot in carcinomatous ulcer, 98
Merycism, 113
31icrobu!bus, 147
Alicro-colon, 2o2
Mikulicz 8 disease sialogniphic appearances, 7
Movnihan’a complete Rostrectomy , radiological
nppcaratices after, earlv and fate, 177,
178
■tiu-scular hvpertonus, locahscsl, causing cas
cado stomach, 43
Kaso pharvuix, closure of, m deglutition, 11
Nerve phrenic, paralysis of, 102
454
INDEX
o
OlAtetnc-«. ra<i]>’^ph\ in, appnrntux ami
BcwtMine^, 3S3
current. 3^3
danffer lo inMlier or firtui, 444
expamre, 3S4
foLiu film dwtanre, 3^3
peneral foclini<jue, 383
iinmobili^ktioii of the fu!ta<t, 383
infonnntion aMulahle from, 383
Ljla\oUage, 383
jtCHition Ilf patient, 384
Kupprm<ion of itiaicmal reKpiratorv mote
inent.383
li'chniqtie of. 3S3
Q^-u:ipIidL’rcta.'<ia. 38
(E.-Kiplm.ni'), anntomt of, 8
atont of. idiopatliie, 33
raremoma of. inorbul anatoinx of, St
perforalton of, 24
radiofoineal api>«irnn<<-i of, 23
aftertntubalion of rodiiim therAp^, 34
ait<M of, 31
t\-p€^ of, 31
dilatation of, duo to Kaitrie leaiona, 33
diVHioea of. 14
filiroiiM of |M><lunriita>o<l. S3
foroiirt iO
malformations of. eonsenital, 18
nomtal, radiototncal app«aranee« of, IS
olMtnirtion of, duo to axlrinmc preaxuro.
eauMM) of. 31
alto of, in relation to rmhoCTaph}. 14
ajiaatie, 38
ataemor, 14
nidioKrspht of. double atcattau methoii, 0
opaque media for, formula of 0, 10
leehtuque of, 0
rOIe of, in deglutition, 11
rpasin of from ulocraiioii, 31
idropatliu, 31
etni-iurp of, la'iiun, e-lioloirt and mortml
anatoms of, SO
t.\]>e3of, annular, 20
radioloimal appcorancre of, 30
tubular SO
ra Jiolosjieal appi arnneea of, S(»
tiimourvor, inalisnant, 31
sanx of ’sV*
Opaque mtal m examination of diapbrugmatie
hemia, ISO
Orlhotnmis of xtomarh 40
Osars , eexta of, 303
cau*ing |ja.«tnc ikiplaecment, 1 M
dcmnnslration of, 373
demioide of, 303
ParK-rra.* anatomy of. 331
ralcilli of, raihologir-al ap|e>anuu'm nf, 3S5
raninoma of. 333
Panerras, et nts of, true and faUe, 334
radiological appeoruneea of, 334
liead of, cnlargcniontx of. duodenum in, 150
nuliotogual examination of barium enema,
3'.2
banum meal, 331
fiuoroseopt of diaphragm and lung
basea in, 333
lateral, with air mllation of stomach, 353
|>lain postero antenor film. 351
tumoufif of, air lasulTlation of atomaeh m
duiimortH of, 43
causing gastne diapUeement. 108
Pancreatitw, chronic, 353
h-pmoiTlia(.K , acute, 353
Parotid gland, anatomx of, 1
calculus of. 4
Peleii organa, female, raihnfrraphv of com
birution of pentoncal inflation and
pertubal injection. 371)
injection of contrast media, 354
injection of opaque Quul, 370
peritoneal gas inflation (hrouch
atxlominal uall, 307
simple or direct, 383
transiitcnne irdlation, 300
uterosalpuisrographt . 370
PcKimelrt. radiological. 353
correction labUn. 390
e»iinMtion of measurement of conjugute
from lateral new, 395
of the inlet, Courinev Gage's method,
technique of, 358
Ilooton 'a mcthoil. technique of 308
Roberts nietliod. teihniqueof, 353
Rowden's method, technique of, 397
Thoms method, trchnii^ue of, 393
oftlioouilct.entero postenordiameler 400
Chosnani and Lapinas methoil tech
nique of, 395
Robes’ method, tecliniquo of 40t)
transierso diameter, 399
PeUxs. abnormabties of, acquinxi, 390
congenital. 390
dcformiticM of, maternal, 300
joints of, rlinnges in, during pregnancj 388
Peptic ulcer follouins Polta Mojiiihan partial
Rustrectomi. 174
eiteaof. 57 Ate alto Gastric ulcer
Pencbolcoatitta 538
PenduodenitLs after rholecjxtectomj. 137
bulbar. 138
cauxing ileus, 148
of tiiinl and fourth {ortions, 137
I’ertienal uiflation in suprarenal di«onIci>. 3>*>
Penstal-us of stomach, 48
Pertstaltic jump, hracntels, m canevr of
atomach, tiO
Pinloneal ravitr free gas m, rau-H^ of, 194
railiologi'-al di monslration of, 193
gas inflation of, through the aIsJoniinal
wall. 307
diugnootic anpIiratioiM of. 3Q9
technique of, 387
INDEX
455
Pentoneal cavity , injection of pas into, 364
transutenne inflation of, 365
“ Persistent fleck ” sign of duodenal nicer, 12-1
Petit’s eventration, 190
Pharj-ngeal sjjace. rflle of, in deglutition, 10
Pharynx, anatom> of, 8
cancer of, 17
diseases of, 14
iliverficiila of, congenital post tonsillar, 15
deep pressure 15
radiological appearances of, 1 7
traction, 17
pressure of, extrinsic 15
radiographj of, indications for, 8
Phrj gian cap defornutv of gall bladder, 320
Placenta prajvia, 43C
diagnosis of bv C3stograph}, 443
Plastic Imitis, fctiologv andpathologj of, 82
radiological appearances of, 82
Plicse, of colon, pathological variations m, 233
tv-pes and forms of, 232
Plum/n^ Vmwn sj ndrome 18
Pneumopentoneum, iransabdommal m diag
noais of pr^tnanev, 387
Poha, anterior left right operation 172
modified operation, with entero snastomosK
m Y. 173
rndiological appearances after,
175
partial gastrectomv, 172
Polya Balfour partial gastrectomy, 173
radiological appearances after 175
Potva Fmaterer partial gastreciotnv, radio
logical appearances after 170
PoUaLue partial gastrectomy, radiological
anpearancea after. 175
Polva >Ioynihan partial gastrectomv, 172
complications of, 174
radiological appearances after, 173
Polvpoxis gastric 8fl
Post cricoid carcinoma 17
Post maturity , radiological estimation of 410
Pregnancy, changes in the pelvic joints in,
388
diagnosis of, bv amniogrophv . 43C
by direct radiograpiiv 386
by use of contrast media, 386
ectopic, diagnosis of uterosalpingograpliv
in, 377
radiological demonstration of, 419
multiple, 414
position and presentation of fictus 412
Pi^sure, use of. in duodenal examination
116 !
P> loroplostv , Finnev’s, nwliological aiipear
ances after, 170
simple, radiological appearances after, 155
Py JoTOsjiasm, diaiznoais from post ulcemfivo .
pyloric stenosis, 74
clTect on gastne evacuation, 56
with gastnc ulcer, 69, 70
Pvlorus acliafasia of, effect on gastne evaciia
tion, SC
with gastno ulcer, 69, 70
Pylorus, antrum of, contracture of, following
gavtro jejunostomv, 167
function of eflect on gastric evacuation, 56
gapuigr, of eancer, 90
obstruction of, organic, effect on gastric
evacuation, 56
with gastnc ulcer, 69, 70
stenosis of. from tumours, tliagnosis from
post ulcerative stenoais, 75
hvpertropfuc, chronic, m adults, differen
tial diagnosis of 105
morbid onatomv of. 103
ndjological appearances of, 103
congenital, letiology of, 102
radiological appearances of, 102
technii^ue m, 102
in adults diagnosis from post nlccrativ e
stenosis, 75
post ulcerative, differential diagnosis of, 74
atages of, 71-74
ulcer of, folloniiig gastro jejunosComv , 164
radiological appearances of. direct aigiis,
Co
undue patency of, effect on gastnc ev acua
tion, 56
n
Rectum, anatomv of, 297
carcinoma of, 297
malformations of, congenital, 300
stricture of. simple, coagenital, 298
post mSaminalorv fibrous, 209
spasmodic, 299
traumatic, 293
Recce’a metboil of cephalometry, 402
of estimating ficlal maturity, 408
Reflex gastro deal 200
Reflex ileo gastric, 200, 221
Relaxatio or evemratio diaphragmatiea, 190
Rieder, pendulum movement of, 239
Rivinus, ducts of, 1
Rolierts method of estimating ftetal maturity,
409
of pelvimetry, 393, 400
Rowden 8 method ofcephalomctrv, 402
of pels imetry , 397
Rumination, 113
Sacio lilac joint, changes in, in pregnancy, 338
Salivary gl^ds. anatomy of, 1
fistula' of, 6
radiology of, 2
tumours of, 7
Scltoeniokcr s operation, radiological appear
oncc's after, 156
Scoliosis causing gastric displacement, 103
Screen examination of duodenum, ll5
Sialeetosis, 7
SiaUtis, chrome, C
Sialogram, parotid, normal J
Sial^niphv, indications f
42G
IKDEX
^laloi?rapIl\, pr^caration of pstiMit for, 3
trrJmw|uo of, -
SitiM invenui {> 0 rtiali.-< n^mmiin)* inromtenum,
243
Sviii pnniliilt*. 1. ?
'•paMin^ >« nsn of tntraut^nnf* <Wth, 43l
.‘'pa*ni. lorali'uvi. raiuins rsjvoiie' stomarh, 48
.''pina liiGdn in firlu*. rs<Iiola{;i«-at domnnstra
lion of. 4.”J
t'p!ftn<‘Jmoptt>»w, 246
Sph”! n. anatOTn\' of. 3i0
rnli'ifuation of. 3i<»
cj^i* cf, hvdutKi, 331
enlan.'ement of, caaiinf! pastne «li-plar^
mmt. 108
eventration of ilinplirapni m, 104
infarct of, T50
pWelxibtlw of, Ml
pt<r>iB of. 330
radiolncaal ap{>earanee<j of. 330
in \ i»rerD{>to“H. 247
tiilj'-rciilou* foci, ralcinmtion of, 330
‘•plcxic flcTure, lU-tcmnon of, nith paa eau-iin? ;
ca-ieade irtoinach, 48
‘‘tratorrhaa, tdirii'nlhie, 230
S!rn«)n • iluet. i
ster«H/-oji\ of wiliianr pUn<l<. 3
Stierimn *ipn m iIeo<ieca1 luUrculoxu. 263
StOTiioeli, lK(^W)tn^eOElw of, 1st
adenoma of, 86
AtllimtoiU of <7
after (weratioti railiolc^eal esanunalion,
teriinirjue of, 131
airinmifUtionof 43
atiatonucAl relation* of, 33
anatorai of 33 !
iineiofna of, 86 i
hH." 30 1
laloiulAtion of. 73 I
cancer of. 8S
» tioI<jjr> of 88
ai.'e and sox incidence of, 88
encc-^ihaloid 03
air iMiCUtion in, 43
fincer pnnt dcfsTl* m, 04
fiincou*, J'3
•ites of anterior or pivienor wall. 97
fandu*. 97
pi I ^nc antniin OS
hour pUm rontrartiins in 91
Rwslivllan , 93
patholixn of. 8S
radioPipical cU»ofic«tion of. 89
recurrent, after foil's 3IomJhan partial
pa*trrctomi, 173
acirrbou*, diapncwi* from pilanc
10.3
i!i{fui«, radiolopical appearancea of, 92
in pjlornr rreem. 92
lf«ralt«»<l. raiiioI<x;ical appearance* of, 89
-itc of. 8S
with pcjilitt ulcer, rmlioloincal appear,
ancea of, Ps
Momach. rsnlia of. ulcer of, radioloipca!
apjiearntu'ee. direct Nipn. 66
eakrade, rau'^ of. 4S
phtaiolopieal, 73
eaiiterviation of. radiolopiial apf>earnnces
after, 1 34
rirrhiML* of. S2
cap and spiil. 48
evxuof. 86
defomutie* of. prM*uTp, from eotoii, !10
from left l.i<lne>, IDS
from hi-er. lOS
fnini neichbounnc orpaiu, 107
from oianano**!, 108
from pancreaa. 108
from prfpnant uleru*, 108
from scoIiobu, 108
from cpleen. IDS
•li-placcment of, in eientratiOR ofdiaphrapm,
192
hi pne.*ure, rau*ea of. 107
diverttcula of. aequimi, 10.3
congenital, 103
rroHion* of, It^moirliapic, 58
eracuation of. rate of. faetoni poiermn?. S3
exanunaiion of. eompree<ioD in, 41
let hnique of, 39
fibromioma of, 86
fibroma of. 86
fibromato*t* of. 82
fUlul^of, external, 84
internal. 84
foreipn bohe* in, 107
form of, 30
funilu* of, cancer of, ripna of, 07
ulcer of, railmlopical appearaacei* of,
direct »ipTi«,C3
hair hall in. raiholopteal appearancM of, 107
hour ela** contraetiins of, cicatni.ial, rimptc,
76
duo to extnn.*ie pre<«ure. 73
malipnant, 91
orpnrue. 77
phi'^tologieal 48. 73
with orpame etenoHi.*. 76
without orcanic nteniww, 75
brperpcru<tal*i4 of. 47
mfianunation of. 80 .8cr ol«> Coetnti*
leather bottle, 82
ineonrtr. 92
le*ionx of caiO'inp a-mphasea! dilatation. 32
lipoma of, 66
Ivmpltonia of, maJipnaiit, 101
ijxnpho.arroina of, 101
miieixa of. S2 .^ce oZ»j Ca>tne mucoas
muccnal rclii-fiaftem of, technKjtie of,
demonatratinn of, 42
mjoma of, 89
iwoj'laem* of. 86 Set alrt Jitomach,
tumour* of
nomtal. anntoini of, 39
antral eplunetcr of, 47
cardiac orifice of. 4 4
1 prwter cun e of. 4 1
INDEX
■<57
Stomach, normal, lejwer cun, e of, 44
lower polo of, 44
mucosa of, 32
peristalsis of, 46
lorui, 45
radiological appearances of, in erect
lateral ciew, 51
m erect position, 43
in prone position, 51
in supine position, 49
tone of, 43
operations on, abolishuig sphinctcric control.
J53. 157
radiological examination foDowing,
132, 157
leaving partial «phincteric control, 131
radiological examination fotlow
mg. 152, 153
leaving spliinctenc control, 151, 154
radiological examination follow-
ing, 152. 154
peristalsis of, effect on evacuation, 56
persimmon bezoar in, 107
polvjioaw of. 86
air insufHation in, 43
radiological appearances of, 86
ntdiolozaal appearances of, m v(9Ce^>ptO''l^,
sarcoma of, clinical features and site of, 100
radiological appearances of, 101
round-celled, 100
spindle-eeJled, iOO
simpto excision of ulcer of, railiological
appearanccN after. 145
etceve resection of. radiological appearances
after, J34
stoaMof follosnng <fuodenal ulcer, ISJ
irvphjlis of. patholog} and radioloetcal
appearances of, 83
thoracic, 33
complete, 183
tonus of, effect on evacuation, 50
tubereulosis of, livpertropluc, 83
ulcerative, 84
tumours of, benign, 80
connovlivo tissue, 86
< vets, 86
glanrlular, 86
railiological app«iran< es of, 86
ulcer of, 57
air insufllation lontmindicato^l ui 43
radiological appearances of, cicatneial
signs, gastne adhesions, 77
contracture of gastro hepatic omen
turn, 77
6ee aho Gastric ulcer
V olvulus of, acute, 1 II
on cardio pv lone axis, 111
on transverse axis. 111
wedge resection of lesser curve, radiological
appearances after, 154
Strawberrv pall bladder, 321
Stoma, malposition of, following gastro
;epinasloinj*, 1 63
Stoma, narrowing of, following pastro Jeiun-
ostomv, 16 >
Sublingual glantl, anatomv of, 1
calculus of, 4
Sobmavdlarj- gland, anstomv of 1
calculus of, 4
Suprarenal glands, anatomv of, 336
calcidcatioa of, diagnosis from pall stones
OJS
tumoaraoF, 356
Swallotring, phvsiology of, 10
Sv-mivatbectomv for Hirsch-prung s disease,
cadiolopicat appearances after, 246
Svinph}-8is pubis, chanpes in, in pregnanev , ,338
Svphiiis of atomaeli, patholopv and radiological
apliearances of, 83
T
Thonn’ method of cephalometrv , 401
of pelvimetrj. 392
Thonum air double contrast enema in caret
noma of colon, 231
in examination of colon, 229
failures m tecliruque of notiiila
tion. 231
m-tutHation of colon. 231
preluninary prppiarotion for, 239
radiological appearancea m firbt
Ntope, 232
m third stage, 234
of patholopicAl variations in
mucosal pattern 233
of pIic-D in aoeond atage, 232
technique of injecticm, 230
tn imcablo colon, 257
in mucous colitLS, 250
Thorotroet, effect of, on reticulo-endothelial
evstem. 349
properties of, 545
vise of. m hepato lienogrophv, 313
f administration of, 348
Thjrroid. tumovu- of, in fcctus radiological
demonstration of, 423
Tongue rflle of, in deglutition. II
TnuLsuterme inilation, tcclinitjiio of, 366
1 nehoberoar. radinlogaal appeerantes of 107
Triplets, radiolr^iial demonstration of 417
Trui-s (omprer-,«r for iw m nuiiologirnl ex
amination, following gostrii opera
tions, 152, 153
1 ulicnMilosis. ilco-(.xxa1, 262
of stonvaeh, 83
Twinuvp.postcnorlpancrcatie) ineisuro of, 39,
50, 332
Twins, ituliological demonstration of, 41*i
TJ
Ulcer, duodenal and gastric, incidcjico of, 57
peptic, air uuufllation of atomach contra
indicated, 43
Eitca of, 30 oho Castne ulcer
simplex, 69
458
INDEX
L'tnhrOM', tpvef, in ntimcnfar; <r8ct exoRima
tion, 3 >
I J«TDwiIpinfK>gTHplir, conthiinflie*tion«, 3T0
diapnortic B|ipIira!lon-* of. 373
tochniijne of, 370
ante(}e-xion of, ilomon^lntion of, 378
biwrnuiite, ilcmon^tretJon of, by ut«ro
nalpingoerapliv, 37G
laninoma of, ilemonxiration of, 378
fibronU of, and raflj prppnancx, diaipmirt
JjBliroon, 370
ra1ci(i<*(l, 303
cJtinomtraJion of. 376. 370
fihn>fnioma of. 301
prT>s;TuiJit. raujiins gaxtrn' dLsplaocmenl, 101
radioera})h^ of, clirp^t, 383
rrlroHcxion of, dcinonxtmion of, 370
Vanx, Q**oph*({pal, 31
Vnt<>r, ampulla of, dilatation of, 143
Vs(«r, Ampulla of, Romial ra<
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